6b - New Surveys

National Amyotrophic Lateral Sclerosis (ALS) Registry

Attach_6b-Screen Shots New Surveys-V2

ALS One-time Survey

OMB: 0923-0041

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Attachment 6b

Screen Shots New Surveys

Table of Contents

Figure 1: Survey 8, Page 1 of 2 3

Figure 2: Survey 8, Page 2 of 2 4

Figure 3: Survey 9, Page 1 of 11 5

Figure 4: Survey 9, Page 2 of 11 6

Figure 5: Survey 9, Page 3 of 11 7

Figure 6: Survey 9, Page 4 of 11 8

Figure 7: Survey 9, Page 5 of 11 9

Figure 8: Survey 9, Page 6 of 11 10

Figure 9: Survey 9, Page 7 of 11 11

Figure 10: Survey 9, Page 8 of 11 12

Figure 11: Survey 9, Page 9 of 11 13

Figure 12: Survey 9, Page 10 of 11 14

Figure 13: Survey 9, Page 11 of 11 15

Figure 14: Survey 10, Page 1 of 3 16

Figure 15: Survey 10, Page 2 of 3 17

Figure 16: Survey 10, Page 3 of 3 18

Figure 17: Survey 11, Page 1 of 9 19

Figure 18: Survey 11, Page 2 of 9 20

Figure 19: Survey 11, Page 3 of 9 21

Figure 20: Survey 11, Page 4 of 9 22

Figure 21: Survey 11, Page 5 of 9 23

Figure 22: Survey 11, Page 6 of 9 24

Figure 23: Survey 11, Page 7 of 9 25

Figure 24: Survey 11, Page 8 of 9 26

Figure 25: Survey 11, Page 9 of 9 27

Figure 26: Survey 12, Page 1 of 3 28

Figure 27: Survey 12, Page 2 of 3 29

Figure 28: Survey 12, Page 3 of 3 30

Figure 29: Survey 13, Page 1 of 4 31

Figure 30: Survey 13, Page 2 of 4 32

Figure 31: Survey 13, Page 3 of 4 33

Figure 32: Survey 13, Page 4 of 4 34

Figure 33: Survey 14, Page 1 of 7 35

Figure 34: Survey 14, Page 2 of 7 36

Figure 35: Survey 14, Page 3 of 7 37

Figure 36: Survey 14, Page 4 of 7 38

Figure 37: Survey 14, Page 5 of 7 39

Figure 38: Survey 14, Page 6 of 7 40

Figure 39: Survey 14, Page 7 of 7 41

Figure 40: Survey 15, Page 1 of 2 42

Figure 41: Survey 15, Page 2 of 2 43

Figure 42: Survey 16, Page 1 of 2 44

Figure 43: Survey 16, Page 2 of 2 45

Figure 44: Survey 17, Page 1 of 7 46

Figure 45: Survey 17, Page 2 of 7 47

Figure 46: Survey 17, Page 3 of 7 48

Figure 47: Survey 17, Page 4 of 7 49

Figure 48: Survey 17, Page 5 of 7 50

Figure 49: Survey 17, Page 6 of 7 51

Figure 50: Survey 17, Page 7 of 7 52



















Figure 1: Survey 8, Page 1 of 2




Figure 2: Survey 8, Page 2 of 2










Figure 3: Survey 9, Page 1 of 11




Figure 4: Survey 9, Page 2 of 11




Figure 5: Survey 9, Page 3 of 11








Figure 6: Survey 9, Page 4 of 11








Figure 7: Survey 9, Page 5 of 11








Figure 8: Survey 9, Page 6 of 11










Figure 9: Survey 9, Page 7 of 11








Figure 10: Survey 9, Page 8 of 11








Figure 11: Survey 9, Page 9 of 11








Figure 12: Survey 9, Page 10 of 11




Figure 13: Survey 9, Page 11 of 11




Figure 14: Survey 10, Page 1 of 3




Figure 15: Survey 10, Page 2 of 3




Figure 16: Survey 10, Page 3 of 3




Figure 17: Survey 11, Page 1 of 9




Figure 18: Survey 11, Page 2 of 9




Figure 19: Survey 11, Page 3 of 9




Figure 20: Survey 11, Page 4 of 9




Figure 21: Survey 11, Page 5 of 9




Figure 22: Survey 11, Page 6 of 9




Figure 23: Survey 11, Page 7 of 9




Figure 24: Survey 11, Page 8 of 9




Figure 25: Survey 11, Page 9 of 9



Figure 26: Survey 12, Page 1 of 3




Figure 27: Survey 12, Page 2 of 3




Figure 28: Survey 12, Page 3 of 3




Figure 29: Survey 13, Page 1 of 4




Figure 30: Survey 13, Page 2 of 4




Figure 31: Survey 13, Page 3 of 4




Figure 32: Survey 13, Page 4 of 4




Figure 33: Survey 14, Page 1 of 7




Figure 34: Survey 14, Page 2 of 7




Figure 35: Survey 14, Page 3 of 7




Figure 36: Survey 14, Page 4 of 7




Figure 37: Survey 14, Page 5 of 7




Figure 38: Survey 14, Page 6 of 7




Figure 39: Survey 14, Page 7 of 7




Figure 40: Survey 15, Page 1 of 2




Figure 41: Survey 15, Page 2 of 2




Figure 42: Survey 16, Page 1 of 2




Figure 43: Survey 16, Page 2 of 2




Figure 44: Survey 17, Page 1 of 7




Figure 45: Survey 17, Page 2 of 7




Figure 46: Survey 17, Page 3 of 7




Figure 47: Survey 17, Page 4 of 7




Figure 48: Survey 17, Page 5 of 7




Figure 49: Survey 17, Page 6 of 7




Figure 50: Survey 17, Page 7 of 7



Page 52 of 52


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