Participant Registry for Blindness and Low Vision Research

* are required fields

Please provide the following information so that we can contact you to let you know about research that might interest you. Your contact information will not be shared with any other organizations.

* First Name

* Last Name

* Address

* City

* Country

* Email

Phone 1

Phone 2

Preferred Contact Method

Please provide the following demographic information so that we can determine which projects will be relevant for you.

Date of Birth Year

Date of Birth Month

Gender

What is the highest level of education you have completed?

Specify

What is your current employment status?
You may select more than one.

Employed full time (35 hours or more per week)

Employed part time (less than 35 hours per week)

Self-employed

Non-paid work only (e.g. volunteer, school program, internship)

Not working but currently looking for work

Not working and not looking for work

Retired

Please tell us about your vision by answering the following questions.

* Which of the following choices best describes your vision?

Specify

Do you work with individuals who are blind or visually impaired?

Job Title

* About how old were you at the onset of your vision loss?

Years

What is your preferred reading medium?
You may select more than one.

Electronic

Braille

Large Print

Regular Print

Audio

Please list any additional disabilities, if any.

* Are you a member of a blindness consumer organization?

Specify

Please tell us briefly how you heard about the participant registry.

Our quarterly newsletter focuses on linking blindness and low vision research to practice and is available electronically. Would you like to be added to the email list to receive the newsletter?