Usher Syndrome Data Collection Program

I am:

an individual with Usher syndrome

a parent or guardian of a minor with Usher syndrome

a researcher or clinical provider

interested in Usher syndrome

Your Contact Information

First Name *

Last Name *

Country *

Street Address *

City *

State *

Province *

ZIP/Postal Code *

Address * (Please enter the entire address)

Email Address *

Phone Number

Please check the box under Personal Information to receive the Usher diagnosis questions and a few optional demographic questions.

Personal Information

How many children are you signing up?

Include me in the USH Trust to be informed of clinical trials and studies

Date of Birth (MM/DD/YYYY) *

Please enter a valid date of birth in MM/DD/YYYY format

Usher Syndrome Type *

Is diagnosis genetically confirmed? *

Please select all race/ethnicities that apply

Please specify additional race/ethnicity

Please select the closest gender identity

Do you have siblings with Usher syndrome?

Professional Information

Usher syndrome type or subtype of interest (select all that apply)

Area(s) of Expertise

Other area of expertise

Job Title

Institution

Department

Website

Work email for directory

Appointments Phone number

Add me to the Specialist Directory