1. Are you eligible to work in the United States?
 
"" 
2. Are you a US citizen or permanent resident?
 
"" 
3. How did you hear about Pathways to Parenthood?
 
250 characters remaining "" 
4. FIRST name
 
250 characters remaining "" 
5. City
 
250 characters remaining "" 
6. State
 
250 characters remaining "" 
7. With this treatment, you will need to travel to the IVF center on a regular (sometimes daily) basis. Which metropolitan area is closest to you?
 
"" 
Please explain "Other"
8. Based on the following address: (11011 King Street, Suite 290, Overland Park, KS, 66210) ... how much time will it take to get to this location? (typical treatment cycle is 11 visits)
 
"" 
9. What is the primary phone number (include area code) to use for contact and leaving messages?
 
250 characters remaining "" 
10. Is this phone number able to receive text messages that can be used to communicate with you? Also, will you be the only person reading your text messages?
 
"" 
11. Have you applied or been screened to be an egg donor before?
 
"" 
If yes, provide the name and location of the donor program(s).
12. Are you currently enrolled as an egg donor in another program?
 
"" 
13. How many times have you donated your eggs?
 
"" 
14. Please provide the racial description of your grandparents?
 
Grandparents Race MGM MGF PGM PGF
African American: Yes Yes Yes Yes
American Indian: Yes Yes Yes Yes
Caucasian: Yes Yes Yes Yes
Chinese: Yes Yes Yes Yes
Hispanic: Yes Yes Yes Yes
Indian (from India): Yes Yes Yes Yes
Jewish: Yes Yes Yes Yes
Mediterranean: Yes Yes Yes Yes
Southeast Asian: Yes Yes Yes Yes
Other: Yes Yes Yes Yes
Unknown: Yes Yes Yes Yes
Please explain "Other":
15. Closest description of your race
 
"" 
If multi-racial, please provide your closest description.
16. What is your date of birth?
 
   
17. Height
 
"" 
18. Weight
 
"" 
19. What is your highest level of completed education?
 
"" 
20. How many cigarettes do you smoke per day?
 
"" 
21. Is your work schedule flexible?
 
"" 
22. When is the last time you had marijuana?
 
"" 
23. How many drinks do you usually consume in a week?
 
"" 
24. When is the last time you have had a non-medical needle piercing of your body (via acupuncture, tattoo, body piercing, ear piercing, etc.)?
 
"" 
25. If a background check were run on you, would it show any significant problems with the law (i.e. theft, fraud, violence, possession of drugs, DUI, custody issues, lawsuits)?
 
"" 
If yes, please explain.
26. What is the most number of consecutive days that you have been incarcerated?
 
"" 
27. Do you or one of your partners in the last 5 years have HIV, Hepatitis B or C, or has been an IV (intravenous) drug user?
 
"" 
28. What kind of contraception do you use?
 













If "Other", please explain.
29. Have you taken a Depo Provero shot within the past year?
 
"" 
30. Are your currently breastfeeding?
 
"" 
31. Do you have both ovaries?
 
"" 
32. What was your age at the onset of menses?
 
"" 
33. Are your menstrual periods regular (when not on the pill)?
 
"" 
34. How long is your monthly cycle (first day of one period to first day of the next)?
 
"" 
35. Have you ever been told by a medical doctor that you were infertile and/or conceived with fertility treatments?
 
"" 
If yes, please explain.
36. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
"" 
37. Have you had any serious illness in the past that may have resulted in hospitalization or the threat of hospitalization?
 
"" 
If yes, describe.
38. Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other medical health professional for any reason?
 
"" 
If yes, when, for how long, for what reason.
39. Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem?
 
"" 
If yes, please list why and date last used.
40. Are you adopted?
 
"" 
41. Our organization uses a secure server for some email communication with you. The server is www.donorapplication.com. Email will come to you from no-reply@donorapplication.com. The domain of donorapplication.com needs to be acceptable to your spam filters to ensure email communication. (Google: "how to add an email address to safe list in (Outlook, Google, Yahoo, etc.)"
 
"" 
42. What is your email address for communication with you regarding your pre-screen application?
   
43. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
44. Verify your password.
   

Please add no-reply@donorapplication.com to your email contact list to prevent our response from being flagged as spam.