ALS Ice Bucket Challenge Progress

 

Current Results for Peer Support Interest Form

1. I am a:

Value

 

Count

 

Percent

Person living with ALS

 

7

 

46.7

Current caregiver of person living with ALS

 

4

 

26.7

Former caregiver

 

3

 

20.0

Caregiver of person living with ALS

 

1

 

6.7

  

2. Name

Latest User Responses:

Asia jami
 

 

 

Elizabeth Dilworth
 

 

 

Barbara McLean
 

 

 

Matt Fortier
 

 

 

Andrew Ross
 

 

 


View All Responses for question #2

3. Address

Latest User Responses:

5932 raisin tree ln Charlotte nc 28215
 

 

 

6300 PELLA ROAD
 

 

 

272 Cambridge Dr
 

 

 

5409 Crestview Road
 

 

 

140 W. Franklin St. #604, Chapel Hill, N
 

 

 


View All Responses for question #3

4. Email

Latest User Responses:

asiajami@icloud.com
 

 

 

dilwortheb@gmail.com
 

 

 

barbaramclean0156@gmail.com
 

 

 

mfortier67@gmail.com
 

 

 

Andrew@andrewross.com
 

 

 


View All Responses for question #4

5. Home Phone number

Latest User Responses:

9802532615
 

 

 

4236671078
 

 

 

919-639-8559
 

 

 

919-909-2298
 

 

 

User Provided No Response
 

 

 


View All Responses for question #5

6. Cell Phone Number:

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

919-961-1845
 

 

 

919-909-2298
 

 

 

919-260-7537
 

 

 


View All Responses for question #6

7. Is it ok to text

Value

 

Count

 

Percent

Yes

 

7

 

87.5

No

 

1

 

12.5

  

8. Preferred Contact Method

Value

 

Count

 

Percent

Email

 

10

 

66.7

Phone

 

3

 

20.0

Text Message

 

1

 

6.7

User Provided No Response

 

1

 

6.7

  

9. Date of Birth

Latest User Responses:

6/8/89
 

 

 

08/30/1987
 

 

 

01-13-1956
 

 

 

07/26/1967
 

 

 

9/30/1971
 

 

 


View All Responses for question #9

10. When were you or person with ALS diagnosed?

Latest User Responses:

2016
 

 

 

August 2019
 

 

 

July 2018
 

 

 

November 28, 2011
 

 

 

May 2017
 

 

 


View All Responses for question #10

11. Which ALS clinic do you or person with ALS attend (or plan to attend)?

Value

 

Count

 

Percent

Duke ALS Clinic

 

8

 

53.3

Atrium Health (Carolinas) Neuromuscular/ALS-MDA Center

 

3

 

20.0

Other

 

2

 

13.3

Vidant Jim "Catfish" Hunter ALS Clinic

 

1

 

6.7

Wake Forest ALS Center

 

1

 

6.7

  

12. If you selected other or do not attend clinic, please tell us why. (Write N/A if not applicable)

Latest User Responses:

Na
 

 

 

I am 31 and My dad, who lives in Tennessee, was diagnosed with ALS last week. I am looking for support and to talk with someone who lives away from their loved one with ALS in order to learn as much as I can and help as much as possible.
 

 

 

N/A
 

 

 

We went to the Duke ALS clinic up until Anne was near the end and she did not want to go anymore.
 

 

 

N/A
 

 

 


View All Responses for question #12

13. Are you a Veteran?

Value

 

Count

 

Percent

No

 

12

 

80.0

Yes

 

3

 

20.0

  

14. Do you have bulbar symptoms where speech is affected?

Value

 

Count

 

Percent

No

 

4

 

50.0

Yes

 

4

 

50.0

  

15. Tell us why you are interested in this program. Please indicate areas you are interested in learning more about or areas you have experience with that may be helpful to others. (Example areas: home modifications, participating in research, families with young children, working caregivers, tracheostomy and ventilator, durable medical equipment and/or wheelchair accessible van purchase, bulbar challenges, grief and loss etc.)

Latest User Responses:

Adjusting to life at 30
 

 

 

I am 31 and My dad, who l...
 

 

 

home modifications, parti...
 

 

 

Have been thinking about ...
 

 

 

I am interested in connec...
 

 

 


View All Responses for question #15

16. I understand that the Program coordinator within the Care Services Department will contact me once this form has been received and reviewed (typically within 1-2 weeks). I understand that a good faith effort will be made to match me with a peer who is familiar with the areas I have identified and that finding a good match may take additional time. I understand that this program is based on available volunteers who are willing to participate and that I/other volunteers can choose to stop participating in the program at any time.

Value

 

Count

 

Percent

I understand

 

15

 

100.0

  

17. Confidentiality: I agree to keep confidential any information shared between myself and my peer, whether personal or medical. Further, I agree that I will not use or disclose to any third party such information or data while participating in the Peer Support Program.

Value

 

Count

 

Percent

I agree

 

14

 

100.0