I give permission to be contacted by researchers about participating in research studies related to spinal cord injury. Name Name - First * M. Last * Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Phone Email * Gender Male Female Are you of Spanish, Latino, or Hispanic origin? Yes No What is your present marital status? Married Divorced Widowed Separated Never married Member of an unmarried couple What is your race? American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander Black or African American White More than one race Other... What is your race? Other... Birth Year Date of Injury Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Which of the following best describes how your injury occurred? Sports (such as diving, skiing, or football) Assault (acts of violence, gunshot wound) Transport (motor vehicle crash, motorcycle or bike crash) Fall Medical or Surgical Complications Other... Which of the following best describes how your injury occurred? Other... What is your spinal cord injury level? - None -C1C2C3C4C5C6C7C8T1T2T3T4T5T6T7T8T9T10T11T12L1L2L3L4L5S1S2S3S4S5 Complete/Incomplete Complete Incomplete What best describes your use of manual or power wheelchairs? Only use manual wheelchair Mostly use manual wheelchair Use manual and power wheelchair about equally Mostly use power wheelchair or scooter Only use power wheelchair or scooter I never use/need a wheelchair/ scooter Can you walk? Not at all A few feet More than 50 feet Additional Contact Information Name * Address Phone * Relationship * How is this person related to you? * For more information about the South Carolina Spinal Cord Injury Research Fund, click here to go to their website.