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Secure IPCRR Questionnaire With Consent

Section 1: Identifying Information

WIRB 20040468 #3860016.0

The purpose of these questions is to provide the IPCRR with contact information so we may keep in touch with the person registering.

1. Person registering (the person with the disorder)

Name

Mailing Address (street, city, state/province, zip)

Country

Phone Number

Cell Phone

Work Phone

Fax Number

E-mail Address

How would you prefer we contact you? (Check all that are okay.)

Gender

Birth Date

Place of Birth (City, State, Country)

Age