The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

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Required format:

xtgDzUHTyqP4MRnfUcA64pYjqNvrpsEtkWp92ciH2ZBFiN4RmKi3rJ7iMridxMEs5zrLYcpH4JP6tUWSDgaNJTBP68uLjbyPW

Interest in Wits Wellness

Thank you for your interest in our research study about Wits Wellness, a free 12-week health & wellness program for adults 50 years old and older.

Please enter your contact information below and someone will be in touch soon to see if you qualify to participate.

If you have any questions, please contact Julie Bobitt, Ph.D at (312) 355-0247 or email jbobitt@uic.edu.

Tracking Notes - Please enter attempts to contact participant with dates and your initials e.g.:

7/1/21 left voice mail - EP
7/2/21 reached daughter who asked us to call back tomorrow - JB

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Participant not enrolled because:

they have been unreachable at recruitment

their desired location was canceled

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Screening Staff Name

* must provide value

Date of Screening

* must provide value

M-D-Y

Hello, this is [staffname] with the University of Illinois, Chicago, Center for Dissemination and Implementation Science. May I speak to ______? I'm giving a you a call because you expressed interest in the Wits Wellness program. [Exchange pleasantries - How are you today?]

I would like to tell you more about the program, and if you are still interested, I will need to ask you some questions to make sure that you are eligible.

[If they are not home leave the following message] Hello, this is [your name] with the University of Illinois Chicago, Center for Dissemination and Implementation Science. I'm returning your call about the Wits Wellness research project. Please feel free to call us back at [give your phone number] or 312-355-0247. Thank you.

Do you have time to talk right now? This call will take about 20 minutes

* must provide value

Yes

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Do you want us to call you back at a different time?

* must provide value

Yes

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When would be a good time to give you a call back?

* must provide value

Thank you for your time Mr./Mrs. ______. Please feel free to call us back if you are interested in Wits Wellness in the future.

[This participant is NOT eligible to participate in our study, because of refusing the phone screening.]

Save and Exit Form

Before we get too much further, I would like to collect/confirm some basic contact information. All of this information is kept in a secure database in our office and if there are any questions that you prefer not to answer, you don't have to. This information will help us verify that you are eligible to participate in the study and allow us to send you information.

First Name:

* must provide value

Last Name:

* must provide value

Email:

Phone Number:

* must provide value

Where would you like to participate in Wits Wellness?

* must provide value

Champaign

Mattoon

St. Joseph

Sterling

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How would you prefer to be contacted? (Check all that apply)

* must provide value

phone call

text

Street address, apt #

* must provide value

City, State ZIP

* must provide value

I will now go over a more thorough description of the study procedures. The Midwest Roybal Center at University of Illinois Chicago has funded this study to determine the effects of Wits Wellness on your health and well-being. The study is known as Wits Wellness. We are looking for adults who are 50 years of age or older to participate in a free 12-week wellness workshop that meets one time a week for 60 minutes. If eligible for the study, you would be randomly assigned to one of two groups. One will start in mid-August and the other will take place in February.

The wellness program is led by trained UI Extension staff members. I would like to mention that the group placement is entirely random and I cannot guarantee which group you will be in. We will be offering the program in-person. However, if something should be mandated by the state that we cannot meet in person (like COVID), we will be able to offer the same program online via Zoom.

As a requirement of the study, we will be asking you to fill out some questionnaires which ask about your health and wellbeing such as your sleep, stress levels, social interaction, memory/attention, and general well-being. We will also ask you to answer some questions by phone which assess things such as memory, attention and decision making three times during the study. The survey will take about 30 minutes each time and the phone call about 15. Regardless of which group you are in, you will complete the survey and phone call at the beginning of the study period, at the end of 12 weeks and then three months after you complete the second survey.

We will provide these surveys to you through your email, however if you are unable to answer them electronically, you can answer the survey questions by phone, or we will send a paper copy to you. No matter which group you are assigned to, you will be paid for completing the surveys. The total you would be paid is $60, which would be $20 for each of the three survey/call questionnaire you complete.

We may also invite you to attend a focus group at the end of the last survey. When you complete the program we will also provide you a brief questionnaire about your thoughts on the program length, the trainers, and program content.
There is no reimbursement for the focus group or end of the training questionnaire.
At this time, do you have any further questions about the study or its procedures?

Would you be interested in participating?

* must provide value

Yes

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Thank you for your time Mr./Mrs. ______. Please feel free to call us back if you are interested in Wits Wellness in the future.

[Participant not eligible - they are not interested in participating.]

Save and Exit Form

Have you previously participated in a Wits Workout program?

* must provide value

Yes

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Thank you for your time Mr./Mrs. ______. Unfortunately, you do not meet the initial criteria for our study. We have set criteria that we must maintain for all our participants and your responses did not fall within the guidelines we have determined for this study.

[Participant not eligible - they have participated in Wits Workout in the past.]

Save and Exit Form

Are you currently participating in any other research study or health and wellness program? If so, could you describe that program to me?

* must provide value

Yes, please describe

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What is your date of birth?

* must provide value

M-D-Y

AGE:

* must provide value

View equation

Thank you for your interest Mr./Mrs. ______. Unfortunately, you do not meet the initial criteria for our study. We have set criteria that we must maintain for all our participants and your responses did not fall within the guidelines we have determined for this study.

[This participant is NOT eligible, because the age is below 50.]

Save and Exit Form

Do you have a diagnoses of Alzheimer's or another related dementia?

* must provide value

Yes

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Save and Exit Form

What is the highest degree or level of school you have completed?

* must provide value

6th grade or lower

7th to 9th grade

10th grade to at least 2 years of college

3 or more years of college

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Do you intend to be available for 12 weeks starting in August?

* must provide value

Yes

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Save and Exit Form

During the first 12 weeks of the study period, do you intend to take an extended vacation lasting more than 2 weeks?

* must provide value

Yes

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Save and Exit Form

The COVID pandemic this past year created the need for many programs to be offered online instead of in-person. We are happy that we are able to currently offer the Wits Wellness program in-person, however should the situation with COVID change and/or if the Governor were to change the mandate again, we would like to ask a few questions regarding your ability to move to an online format.

Do you own, or have access to, a smart phone, tablet, laptop or desktop computer that you could use to join remote classes?

* must provide value

Yes

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Does that device have a functioning video camera? (i.e. a camera that faces you so we can see you and you can see others in the class)

* must provide value

Yes

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Do you have access to a stable WiFi or internet connection?

* must provide value

Yes

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Save and Go to Next Form

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.