Clinical Trials Notification Program

CRIA provides notice to persons with HIV infection who might be candidates for current and/or future clinical trials. Sign up and receive a FREE subscription to CRIA UPDATE, our quarterly treatment educational newsletter. You will also receive advance notification about new clinical trials at CRIA and announcements for our monthly HIV/AIDS forums. Please mail the form to: CRIA Trials Notification, 230 West 38th St., 17th Floor, New York, NY 10018 or FAX the form to: 212-924-3936. If you have any questions regarding the form or would like to talk to someone about clinical trials please call 212-924-3934.

All information will be kept strictly confidential

Date_________________________________

__________________________________________________________
First Name                        Middle Initial                        Last Name

__________________________________________________________
Address                                                                    Apartment number

__________________________________________________________
City                                                      State                                   Zip Code

OK to contact by: Phone? ____YES  ____NO

OK to send Mail? ____YES  ____NO

____________________
Home phone

OK to leave message? ____YES  ____NO

___________________________________
Business phone/Other phone contact

OK to leave message?____YES  ____NO

Gender: Male_____  Female____

Date of Birth:_____________________ Month / Day / Year

Year of HIV diagnosis________

Most recent CD4 count(T-Cell)____________ Date_______________

Height_________ Most recent weight___________ Date___________

Weight loss in the past 6 months?________ Lbs.

Have you ever taken antiretroviral medication to treat HIV infection?

YES_______  NO_______  Don't know_______

Have you ever taken a protease inhibitor drug?

YES_______  NO_______  Don't know________

Please circle which, if any, of the medications you have ever taken:

AZT(Retrovir) 3TC(Epivir) d4T(Zerit) ddI(Videx) ddC(HIVID)

abacavir(1592) nevirapine(Viramune) delavirdine(Rescriptor)

efavirenz(Sustiva) Adefovir dipivoxil(Preveon) indinavir(Crixivan)

saquinavir(Invirase or Fortovase) ritonavir(Norvir) nelfinavir(Viracept)

amprenavir

The following information is for statistical purposes only and is optional:

Mode of transmission (how you became infected) -- check those that apply:

Injection Drug Use______
Blood Products______
Heterosexual sex______
Homosexual sex______

Race/Ethnicity:

African-American______
Native American______
Asian/Pacific Islander______
Latino/a______
White______
Other______

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