Alzheimer's
Foundation of America

Screening: Data Collection Form

Organization*
Screening Location*
Screening Date*
MM slash DD slash YYYY
Number of people screened*
Number of people with below threshold score*
Number of other individuals who did not get screened, but came in to pick up educational materials and participate in other activities you offered
Upload file(s)
Additionally, please upload any completed Voluntary Participant Surveys. If you are having trouble uploading the surveys, please submit them by using one of the following options:
• Email – screening@alzfdn.org
• Fax- 646-638-1546
• Mail- National Program Coordinator, 322 8th Ave, 7th Floor, New York, NY 10001
Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 2 GB.

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Email*
Name*
First Last
Organization (if applicable)
Address*
Street Address Address Line 2 City State/Province ZIP / Postal Code
What encouraged you to sign up?
- I'm a family caregiver
- I'm a dementia care professional (i.e. doctor, nurse, social worker, home health aide)
- I'm living with a dementia-related illness
- I'm interested in learning more about AFA