1. What is your FIRST name?
 
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2. What is your LAST name?
 
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3. What is your date of birth?
 
   
4. What is your mailing address?
 
Address Street Address City State Zip/Postal Code Country
Address:          
5. What is the primary phone number (include area code) to use for contact and leaving messags?
 
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6. What is your primary email address?
 
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7. What is your height?
 
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8. What is your weight?
 
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9. What race would you most likely be affiliated?
 
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If "Other", please explain.
10. Select all that apply to your ancestors. Use the following as a guide: MGM=Maternal Grandmother, MGF=Maternal Grandfather, PGM=Paternal Grandmother, PGF=Paternal Grandfather)
 
Ancestry Mother Father MGM MGF PGM PGF
African American: Yes Yes Yes Yes Yes Yes
Asian: Yes Yes Yes Yes Yes Yes
Caucasian/European: Yes Yes Yes Yes Yes Yes
Eastern European (Ashkenazi) Jewish: Yes Yes Yes Yes Yes Yes
Mediterranean (Greek, Italian): Yes Yes Yes Yes Yes Yes
Hispanic: Yes Yes Yes Yes Yes Yes
Indian (from India): Yes Yes Yes Yes Yes Yes
Southeast Asian (Laotian, Vietnamese, Cambodian): Yes Yes Yes Yes Yes Yes
French Canadian: Yes Yes Yes Yes Yes Yes
Cajun: Yes Yes Yes Yes Yes Yes
Unknown: Yes Yes Yes Yes Yes Yes
Other: Yes Yes Yes Yes Yes Yes
11. Are you adopted?
 
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12. What is your natural hair color?
 
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13. What is your natural hair type?
 
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14. What is your eye color?
 
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15. What is your complexion?
 
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16. What is your current occupation?
 
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17. Are you eligible to work in the United States?
 
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18. Which best describes your level of education?
 
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Please Explain
19. What is your marital status?
 
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20. How many children have you given birth to?
 
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21. Do you currently smoke cigarettes?
 
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22. Have you ever smoked cigarettes?
 
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23. Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular, or subcutaneous injection?
 
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If yes, please explain.
24. Do you have a clotting disorder for which you have received human-derived clotting factor concentration?
 
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If yes, please explain.
25. Have you ever received growth hormone made from human pituitary glands?
 
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If yes, please explain.
26. Have any of your blood relatives ever had Creutzfeldt-Jakob disease?
 
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If yes, please explain.
27. Have you spent 5 or more years cumulative in Europe?
 
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If yes, please explain.
28. From 1980 through 1990, were you a member of the US military, a civilian military employee or a dependent of a member of the US military, residing in US military bases in Northern Europe (Germany, Belgium and the Netherlands) for 6 months or more, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, Italy) for 6 months or more from 1980 through 1996?
 
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If yes, please explain.
29. Do you agree to answer all questions truthfully and to the best of your ability?
 
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30. Do you understand the process involves approximately 20 days of injections and may require approximately 6-10 office visits?
 
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31. Do you understand this is a serious committment and will require you to comply with all instructions and appointments even if they are not convienient for your work schedule?
 
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32. Do you understand and agree that your health history, test results, and photographs will be shared with potential recipients?
 
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33. How did you hear about our program? Please provide which website, radio station, newspaper or magazine.
 







Please Explain
34. What is your email address for communication with you regarding your pre-screen application?
   
35. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
36. Verify your password.
   

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