• People living with Alzheimer's Disease: Project Submission Form

    Hello. Thank you for taking the time to respond!

  • Please fill out the questionnaire below. It should only take a few minutes.  Once submitted, you may be contacted by a GENUINE Team member for a follow-up video interview to be viewed by our team and clients.

     

    If you experience difficulty taking this survey or have questions about the project, please contact GENUINE at realpeople@genuinerp.com  or (212) 966-3211 x 620.

     

    If you have any questions about the information you provide to us, you can read GENUINE's Privacy Policy.

     

    Okay, let's get started!

  • Who is filling out this form?*

  • Good to know, thank you!

    If you are a care partner, please keep in mind that this survey has been written for the person diagnosed with Alzheimer's disease, so "you" will refer to that person. 

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  • Are you legally permitted / allowed to work in the United States?*

  • For this project, we want to feature people engaging in activities that they love, so we'd like to learn more about you, your life, your interests, and what makes you unique.

  • What are some of the activities you currently like to do? Please check all that apply.*

  • During this survey, we will be asking you about your medical history/health as it relates to your diagnosis of Alzheimer's disease.  Please select "I permit" below if you or your care partner mentioned above are willing to share information about your health as it relates to your diagnosis of disease for the purposes of recruiting for this project.

     

    MEDICAL CONDITIONS

    Subject to your agreement to the waiver below, please share information regarding any medical conditions that you may have and are comfortable discussing publicly for potential projects.  You acknowledge and understand that your personal health information may be protected from disclosure by the Health Insurance Portability and Accountability Act ("HIPAA") and other privacy laws.  By selecting, "I permit" below, you consent to GENUINE electronically storing the personal health information that you disclose and reviewing it for purposes of contacting you about future projects for which you may be suited.

  • By selecting one of the options below, you acknowledge that you have read and understand the above statement.*

  • Now we'd like to hear more about your diagnosis and experiences living with Alzheimer's disease.

  • Which of the following have you been diagnosed with? (please select all that apply)*

  • Have you been diagnosed with this condition(s) by a health care professional (HCP)?*

  • If requested at a later time, would you be able to provide a Physician's Note confirming your diagnosis?*

  • Are you participating in (or have you participated in) any clinical trials for medications related to your Alzheimer's condition?*

  • If selected for this project, please let us know which filming option(s) are possible? Please check all that apply.*

  • Have you recently submitted for any on-camera and/or research project that is similar to this project?*

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  • Thank you so much.  Just a few more questions and you'll be done.

     

  • What is your age range?*
  • What is your ethnicity/race?*

  • Our company and our client do not discriminate on the basis of gender identity or gender expression. In order to track the effectiveness of our recruiting efforts and ensure we consider the needs of our project, please consider the following question optional.

  • What is your gender?*

  • As a part of the final selection process, would you consent to a Criminal and Social Media Background Check?*
  • Are you or any household members currently employed by any of the following?*
  • Please answer the following statements. *
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  • How did you hear about this project?*

  • Thank you so much for taking the time to answer all of our questions.

     

    Please click on the "Submit" button to complete this questionnaire.

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