UNLV PROSPER Trial — Pre-Screening

Before we begin — screening consent

This screening form collects information to help the UNLV Human Capability Lab research team determine whether you may be eligible for the PROSPER trial. Completing this form does not enrol you in the study.

Your answers will be reviewed by study personnel, who may contact you using the details you provide. Your information will be kept confidential and used only for eligibility review purposes. Participation in this screening is voluntary — you may stop at any time.

Do you agree to answer the following screening questions so the research team can assess whether you may be eligible for this study?

Do you agree to answer the screening questions?

Yes No

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1980)

City and State

Where do you currently live?

Thank you for your time. If do not meet the criteria to enroll into this particular study would you like us to contact you again if another study comes up for which you might qualify to participate in?

Yes No

Future Study Interests

Have you had a lower limb amputation or absence at the ankle level or above (on one or both sides)?

Yes No

Do you use a prosthetic limb for walking?

Yes No

Do you use your prosthetic limb regularly for walking — that is, as a regular part of your daily activities?

Yes No

Are you able to walk for at least 3 minutes at a time, with or without a walking aid or assistive device?

Yes No

Was your prosthetic limb fitted by a trained prosthetist?

Yes No

Are you able to travel to the UNLV campus in Las Vegas, Nevada, for study visits?

Yes No

Which side(s) is your lower limb amputation on?

Unilateral – Left side Unilateral – Right side Bilateral (both sides)

My LEFT lower limb amputation level is:

Symes (through the ankle) Transtibial (below the knee, above the ankle) Knee disarticulation (through the knee) Transfemoral (above the knee, below the hip) Hip disarticulation (through the hip) Hemipelvectomy (through the pelvis) Other

You selected 'Other' for your left side — please briefly describe the level of your left lower limb amputation.

My RIGHT lower limb amputation level is:

Symes (through the ankle) Transtibial (below the knee, above the ankle) Knee disarticulation (through the knee) Transfemoral (above the knee, below the hip) Hip disarticulation (through the hip) Hemipelvectomy (through the pelvis) Other

You selected 'Other' for your right side — please briefly describe the level of your right lower limb amputation.

The cause of my amputation(s) is: (Select all that apply)

Traumatic Vascular Congenital Other

You selected 'Other' for cause of amputation — please briefly describe the cause.

I have an upper limb amputation or absence at the wrist or above (on one or both sides):

Yes No

The skin on my residual limb(s) has sore spots:

Never Rarely Sometimes Frequently Always

The skin on my residual limb(s) has ulcers (open sores):

Never Rarely Sometimes Frequently Always

The skin on my residual limb(s) breaks down when I walk:

Never Rarely Sometimes Frequently Always

I have pain in my residual limb(s) when I walk:

Never Rarely Sometimes Frequently Always

On a scale of 0–10, where 0 is the most uncomfortable socket fit you can imagine and 10 is the most comfortable, how would you score the comfort of your socket at the moment?

Enter a whole number from 0 (least comfortable) to 10 (most comfortable).

Health conditions

Answering 'Yes' to any of these does not necessarily preclude your participation in this study. Please select all that currently apply.

Do you have any of the following? (Select all that apply)

If you answered 'Yes' to any health conditions above, please provide further information. You can also note anything you are unsure about, or anything not listed that may be relevant to the study.

Are you currently pregnant, or is there any chance you could be pregnant?

Yes No Not sure

Are you currently receiving physical therapy treatment to improve your walking?

Yes No

Do you think you will likely be receiving physical therapy treatment to improve your walking in the next six months?

Yes No

Have you ever used a treadmill since your lower limb amputation?

Yes No

Have you walked on a treadmill for 60 minutes or more in total since your amputation?

Yes No

My age (in years):

My sex assigned at birth:

Male Female Other Don't wish to answer

My gender:

Woman Man Transgender Woman Transgender Man Non-binary Agender (I don't identify with any gender) Gender not listed Don't wish to answer

My gender is...

I am of Hispanic, Latino, or of Spanish origin:

Yes No Don't wish to answer

I would describe myself as: (select one or more)

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Don't wish to answer

How did you hear about this study?