The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

3AFU6w4zBQIYKiTjfpbBGYXdApeP6p844po9qyg37ZDG6XCRsXCNx3kLTZdBo3r78FAgbhEskL3C32mNjGPiWDGe8wI4fzX68Zr

CHIP Study Screening

Thank you for your interest in our study! Please fill out the survey below and we will contact you to let you know if your child is eligible for the study.

We look forward to talking with you.

-CHIP Study Team

Please choose one of the following options:

* must provide value

I am a teen or parent/caregiver interested in learning more about this study

I am a health care provider referring a patient to this study

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Name of referring provider/staff:

* must provide value

With which institution/hospital (are you/is this) provider affiliated?

* must provide value

Optional referral notes:

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Parent/caregiver first and last name:

* must provide value

Child/teen first and last name:

* must provide value

Parent/caregiver email address:

* must provide value

Parent/caregiver phone number:

* must provide value

Okay to send text messages to this phone number?

Yes

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Time zone:

* must provide value

Pacific

Mountain

Central

Eastern

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Best time/day to call?:

Is your child/teen between the ages of 11 and 18?

* must provide value

Yes

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Which best describes your child?

* must provide value

Seen by a medical provider and diagnosed with a concussion

Seen by a medical provider and diagnosed with a more severe brain injury (head bleed, skull fracture, etc.)

Not yet seen by a medical provider, but believes they have/had a concussion

Other

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Please tell us more:

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How is your child feeling now?
Note: post-concussive symptoms can include: headache, dizziness, fatigue, irritability, anxiety, trouble sleeping or sleeping too much, loss of concentration, memory issues, ringing in the ears, blurry vision, noise and light sensitivity, etc.

* must provide value

They are fully back to all activities and are NOT experiencing any post-concussive symptoms

They are able to do some activities, but are still experiencing post-concussive symptoms

They struggle to do anything right now and are experiencing post-concussive symptoms

Other

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Please tell us more:

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.