Applied Therapeutics AT-007-1005
Rater Information Form

Instructions: Please provide all information requested below. All sections must be completed in order to proceed to the Rater Qualification Questionnaire (RQQ).

Site and Rater Information

Site Identification

Site Name: *

Site Number: *

Principal Investigator (PI) Name: *

Main Site Contact (Name and Phone): *

Study Coordinator Name and Email Address: *

Site Mailing/Shipping Address: *

Rater Identification

Name: *

Email: *

Phone: *

Fax (if applicable):

Rater Qualification Questionnaire

A. Rater Educational Qualifications

Please help us establish your educational qualifications by listing all of your advanced degrees (i.e., degrees higher than a high school diploma), beginning with your most recent advanced degree.

Degree Type *

Year *

Specialty *

License *

Degree Type

Year

Specialty

License

Degree Type

Year

Specialty

License

Degree Type

Year

Specialty

License

B. General Rater Experience

Please help us to establish your general rater experience by providing the following information.

1. Experience with adults diagnosed with Sorbitol Dehydrogenase (SORD) Neuropathy *

Years *

Months *

Describe

2. Experience with adults with other related neuromuscular disorders (Please list diagnosis) *

Years *

Months *

Describe

3. Experience with adolescent/teenagers with other related neuromuscular disorders (Please list diagnosis) *

Years *

Months *

Describe

4. Experience with natural history studies, clinical research, or clinical trials *

Years *

Months *

Describe

Other Relevant Experience

C. Rater Experience with AT-007-1005 Measures

Please help us to establish your general experience with the measures used in this study by providing the following information.

1. Charcot-Marie-Tooth Functional Outcome Measure (CMT-FOM)

CMT-FOM Previous Experience : Years *

Months *

Have you completed this assessment in the past 12 months? *

Approximate number of administrations: *

Medical Diagnoses of patients tested:

Administration setting(s):

Specifics

Clinical practice
Clinical trial
Other (describe)

Others (describe)

Were you selected by your site to administer this scale in the AT-007- 1005 study? *

2. Charcot-Marie-Tooth Pediatric Scale (CMT-PedS)

CMT-PedS Previous Experience : Years *

Months *

Have you completed this assessment in the past 12 months? *

Approximate number of administrations: *

Medical Diagnoses of patients tested:

Administration setting(s):

Specifics

Clinical practice
Clinical trial
Other (describe)

Others (describe)

Were you selected by your site to administer this scale in the AT-007- 1005 study? *

3. CMT Examination Score Version 2 (CMTESv2)

CMTESv2 Previous Experience : Years *

Months *

Have you completed this assessment in the past 12 months? *

Approximate number of administrations: *

Medical Diagnoses of patients tested:

Administration setting(s):

Specifics

Clinical practice
Clinical trial
Other (describe)

Others (describe)

Were you selected by your site to administer this scale in the AT-007- 1005 study? *

4. Four-Square Step Test (FSST)

FSST Previous Experience : Years *

Months *

Have you completed this assessment in the past 12 months? *

Approximate number of administrations: *

Medical Diagnoses of patients tested:

Administration setting(s):

Specifics

Clinical practice
Clinical trial
Other (describe)

Others (describe)

Were you selected by your site to administer this scale in the AT-007- 1005 study? *

5. Columbia-Suicide Severity Rating Scale (C-SSRS)

C-SSRS Previous Experience : Years *

Months *

Have you completed this assessment in the past 12 months? *

Approximate number of administrations: *

Medical Diagnoses of patients tested:

Administration setting(s):

Specifics

Clinical practice
Clinical trial
Other (describe)

Others (describe)

Were you selected by your site to administer this scale in the AT-007- 1005 study? *

6. Nerve Conduction Studies (NCS)

NCS Previous Experience : Years

Months

Have you completed this assessment in the past 12 months?

Board certified in Electrodiagnostic Medicine OR Neuromuscular Medicine OR Certified Nerve Conduction Technologist:

Administration setting(s):

Specifics

Clinical practice
Clinical trial
Other (describe)

Others (describe)

Were you selected by your site to administer this scale in the AT-007- 1005 study?

Upload CV *

Click or drag a file to this area to upload.

If you have a valid C-SSRS Certificate issued within the past 2 years, please upload C-SSRS Certificate here *

Click or drag a file to this area to upload.

Applied Therapeutics AT-007-1005Rater Information Form

Site and Rater Information

Site Identification

Rater Identification

Rater Qualification Questionnaire

A. Rater Educational Qualifications

B. General Rater Experience

C. Rater Experience with AT-007-1005 Measures

Applied Therapeutics AT-007-1005
Rater Information Form