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 

Rater Identification  


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.  

B. General Rater Experience 


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


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) 


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


3. CMT Examination Score Version 2 (CMTESv2)


4. Four-Square Step Test (FSST)


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


6. Nerve Conduction Studies (NCS)  

Click or drag a file to this area to upload.
Click or drag a file to this area to upload.