MMAS-8 Student Lic

MMAS-4 Student Licensing Questionnaire

* Indicates required field

Name *

First

Last

Date *

Email *

Phone Number *

Address of University *

Line 1

Line 2

City

State

Zip Code

Country

Location of Study/Clinical Trial? *

Date Study/Clinical Trail will begin? *

Will the Morisky Scale be used in publication? *

YES NO

Name of Study? *

Translation *

Name of health condition (eg. hypertension, diabetes)? *

Name of Medication(s) taken? *

What are the interval periods of administering the Morisky Scales? *

Will there be any third party organization administering the Morisky Scales? *

Do you track the dynamic level of medication adherence with changing measures of disease or the severity of mental health conditions? *

Will the Morisky Scales be included with a battery of other assessments? If so, please list. *

Additional Comments: *

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