Please enable JavaScript in your browser to complete this form.Applied Therapeutics AT-007-1005Rater Information FormInstructions: Please provide all information requested below. All sections must be completed in order to proceed to the Rater Qualification Questionnaire (RQQ). Site and Rater InformationSite 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 TypeYearSpecialtyLicenseDegree TypeYearSpecialtyLicenseDegree TypeYearSpecialtyLicenseB. 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 *YesNoYears *Months *Describe2. Experience with adults with other related neuromuscular disorders (Please list diagnosis) *YesNoYears *Months *Describe3. Experience with adolescent/teenagers with other related neuromuscular disorders (Please list diagnosis) *YesNoYears *Months *Describe4. Experience with natural history studies, clinical research, or clinical trials *YesNoYears *Months *DescribeOther Relevant ExperienceC. 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? *YesNoApproximate number of administrations: *Medical Diagnoses of patients tested:Administration setting(s):SpecificsClinical practiceClinical trialOther (describe)Others (describe)Were you selected by your site to administer this scale in the AT-007- 1005 study? *YesNo2. Charcot-Marie-Tooth Pediatric Scale (CMT-PedS)CMT-PedS Previous Experience : Years *Months *Have you completed this assessment in the past 12 months? *YesNoApproximate number of administrations: *Medical Diagnoses of patients tested:Administration setting(s):SpecificsClinical practiceClinical trialOther (describe)Others (describe)Were you selected by your site to administer this scale in the AT-007- 1005 study? *YesNo3. CMT Examination Score Version 2 (CMTESv2)CMTESv2 Previous Experience : Years *Months *Have you completed this assessment in the past 12 months? *YesNoApproximate number of administrations: *Medical Diagnoses of patients tested:Administration setting(s):SpecificsClinical practiceClinical trialOther (describe)Others (describe)Were you selected by your site to administer this scale in the AT-007- 1005 study? *YesNo4. Four-Square Step Test (FSST)FSST Previous Experience : Years *Months *Have you completed this assessment in the past 12 months? *YesNoApproximate number of administrations: *Medical Diagnoses of patients tested:Administration setting(s):SpecificsClinical practiceClinical trialOther (describe)Others (describe)Were you selected by your site to administer this scale in the AT-007- 1005 study? *YesNo5. Columbia-Suicide Severity Rating Scale (C-SSRS)C-SSRS Previous Experience : Years *Months *Have you completed this assessment in the past 12 months? *YesNoApproximate number of administrations: *Medical Diagnoses of patients tested:Administration setting(s):SpecificsClinical practiceClinical trialOther (describe)Others (describe)Were you selected by your site to administer this scale in the AT-007- 1005 study? *YesNo6. Nerve Conduction Studies (NCS) NCS Previous Experience : YearsMonthsHave you completed this assessment in the past 12 months?YesNoBoard certified in Electrodiagnostic Medicine OR Neuromuscular Medicine OR Certified Nerve Conduction Technologist: YesNoAdministration setting(s):SpecificsClinical practiceClinical trialOther (describe)Others (describe)Were you selected by your site to administer this scale in the AT-007- 1005 study?YesNoUpload 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. Submit