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
First Name Middle Initial Last Name
OK to contact by: Phone? ____YES ____NO
OK to send Mail? ____YES ____NO
OK to leave message? ____YES ____NO
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:
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______
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication CRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.