This information will be used to compile member statistics and to assist our group in lobbying for increased funding for CJD research as well as increasing CJD awareness. No personal information will be publicly posted unless you specify otherwise. Thank you for your continued efforts!
Your Name
Your Email Address
Name of CJD Victim
State & Country where victim lived
Age
Date of Death (if applicable) Please enter month, day, year
Check if CJD is listed on death certificate
Check if ever in military
Occupation
Length of illness
Was 14-3-3 test done? and where?
Was biopsy performed? and where?
Was autopsy done? and where?
Check if CJD is familial (this will remain confidential also)
Did you have problems getting an autopsy?
Did you have problems with funeral arrangements?
Vaccinations in last 10 years?
Did victim travel out of the country?
Nationality/ethnic group of victim:
Initial diagnosis:
First 3 major symptoms in order of appearance:
What is your biggest concern regarding CJD?
Are you aware of other confirmed cases in your area?
Your relationship to the victim?
Your mailing address:
If you would like to be listed as a contact in your area, provide your phone number:
Would you like to receive our discussion group correspondence by email?
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