The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

8JJVnsXnhjwYmAuBcGKCwL4nkeMXL5h

Transforming Your Mental Health Through Prayer and Healing Survey

Returning?

A A A

Please fill in the appropriate fields.

Page 1 of 12

First name from eligibility screen: ______

Last name from eligibility screen: ______

Church ID from eligibility screen: ______

Enter Respondent ID:

Respondent ID from eligibility screen: ______

Was participant eligibile?

View equation

Respondent First Name:

* must provide value

Respondent Last Name:

* must provide value

What is your best contact phone number?

* must provide value

What is your email address?

(If you do not have an email address, enter "letstriumphtogether@cumc.columbia.edu".)

* must provide value

CHURCH NAME:

* must provide value

Type of encounter (in-person, virtual, etc.)

* must provide value

In-person

Telephone

Video call (virtual)

Other

reset

Date of interview (M-D-Y)

* must provide value

M-D-Y

Select name of person conducting interview:

* must provide value

Enter Interviewer name: (format: Lastname, Firstname)

How old are you?

* must provide value

Would you say you are...

Note: Offer choices

less than 18

18 to 29

30 to 39

40 to 49

50 to 59

60 to 69

70 to 79

80 to 89

90 and greater

Unknown

Refusal

reset

What is your primary residence? In what borough is your primary residence?

* must provide value

Bronx

Brooklyn

Manhattan

Staten Island

Queens

Mount Vernon

Other

Unknown

Refusal

reset

PLease select "Eligibility Screen"

* must provide value

Eligibility Screen

reset

CHWs: Please select "Eligibility Screen" to perform the eligibility screen.

RAs: Please select the appropriate administration for the assessment. You will get a message asking you to "End Survey" or "Return and Edit Response". Click "End Survey" to continue to the assessment.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.