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 North American 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:

sNpdxL8ExURQA7nJg9dEfQaXFncMzZ33z5Nx4YjL

ThrYve Payment Information

Please complete the survey below.

Thank you!

For Payment Only
The following information is only collected for payment purposes. Only the individuals providing payment will see this information. It will not be shared with anyone for any reason other than to provide payment.

Interview date:

M-D-Y

Interviewer's name:

If you selected other, please specify:

Are you collecting information to issue a new Clincard or for a Replacement Clincard?

New Clincard Issued

Replacement Clincard Issued

reset

Referral - Were you referred to us by someone?

* must provide value

Yes

reset

Referral Name - What is the first and last name of the person that referred you?

* must provide value

Referral Phone Number- What is the phone number of the person that referred you?

* must provide value

Referral Email - What is the email address of the person that referred you?

Parent - What is your first, middle and last name?

* must provide value

Parent - What is your date of birth?

* must provide value

Parent - What is your home phone number?

Parent - What is your cell phone number?

* must provide value

Parent - What is your email?

* must provide value

Parent - Do you prefer to be contacted by email or text?

* must provide value

Text

reset

Parent - What is your street address (e.g., 123 Main St).

* must provide value

Parent - What city do you live in?

* must provide value

Parent - What is your zip code?

* must provide value

Below is a system for making a unique ID for your survey. In no way does this allow anyone to trace your responses back to you.

Parent ID Box 1 - 3rd letter of your first name.

* must provide value

Parent ID Box 2 - 2nd letter of your mother's first name.

* must provide value

Parent ID Box 3 - Your middle initial

* must provide value

Parent ID Box 4 - 2nd letter of your last name.

* must provide value

Parent ID Box 5 - 1st letter of your birth month

* must provide value

Parent Study ID: ______ ______ ______ ______ ______

Youth Full Name

* must provide value

Youth - What is your Date of Birth?

* must provide value

Youth - What is your cell phone number?

* must provide value

Youth - What is your email?

* must provide value

Create the unique ID for the youth, below.

Youth ID Box 1 - 3rd letter of youth's first name.

* must provide value

Please spell your mother's first name
Youth ID Box 2 - 2nd letter of youth's mother's first name.

* must provide value

Youth ID Box 3 - Youth's middle initial.

* must provide value

Youth ID Box 4 - 2nd letter of youth's last name.

* must provide value

Youth ID Box 5 - 1st letter of youth's birth month.

* must provide value

Youth Study ID: ______ ______ ______ ______ ______

Corrected ID (Staff Use ONLY)

Youth - Do you use the same contact information as your parents (address, phone, email)?

Yes

reset

Youth - What is your home phone number?

Youth - What is your cell phone number?

* must provide value

Youth - What is your email?

* must provide value

Youth - Do you prefer to be contacted by email or text?

Text

reset

Youth - What is your street address (e.g., 123 Main St).

* must provide value

Youth - What city do you live in?

* must provide value

Youth - What is your zip code?

* must provide value

Parent - Card Token Number: Please indicate the token number.

Parent - Please indicate the expiration date.

Parent - Signature: Please provide your signature that indicates you have completed this form to the best of your ability.

Add signature

Youth - Card Token Number: Please indicate the token number.

Youth - Please indicate the expiration date.

Youth - Signature: Please provide your signature that indicates you have completed this form to the best of your ability.

Add signature

Thank you. That's the end of our interview.

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.