Dear Prospective Donor:

Thank you for your interest in the egg donor program at Reproductive Medicine Associates of Michigan. At RMA of Michigan, we recognize the level of compassion and dedication it takes. Our egg donor program is an anonymous program. While no identifying information is revealed to the recipient, detailed physical characteristics, psychological, and medical profiles are provided to the recipient as part of their selection process.

Once you complete this online pre-screen application it will be reviewed by our Egg Donor Team and you will be contacted about the status of your application. If you are selected, we will begin the next phase of screening, which will include completing a full questionnaire.

IMPORTANT TRAVEL RESTRICTIONS FOR EGG DONORS

** Please note that the FDA has issued guidelines related to egg donation and the ZIKA virus. If you have traveled to any of the following locations in the prior 6 months, or plan to travel there in the next 3 months, this may affect your ability to donate **
• Zika Virus in Cape Verde
• Zika Virus in the Caribbean
Currently includes: Aruba; Barbados; Bonaire; Curaçao; Dominican Republic; Guadeloupe; Haiti; Jamaica; Martinique; the Commonwealth of Puerto Rico, a U.S. territory; Saint Martin; Saint Vincent and the Grenadines; Saint Maarten; Trinidad and Tobago; U.S. Virgin Islands
• Zika Virus in Central America:
Currently includes: Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama
• Zika Virus in Mexico
• Zika Virus in the Pacific Islands
Currently includes: American Samoa, Marshall Islands, Samoa, Tonga, Fiji, Micronesia
• Zika Virus in South America
Currently includes: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Suriname, Venezuela
• 2016 Summer Olympics (Rio 2016)

We at RMA of Michigan and our recipients, express a deep gratitude and respect for the gift that you give so generously. We look forward to meeting you in the near future.

Sincerely,

Jaclyn RN
Egg Donor Coordinator
1. Were you referred by a current or previous donor?
 
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Name of referring donor:
2. How did you hear about our egg donor program?
 
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If Other, please explain:
3. Are you a US citizen or permanent resident of the USA?
 
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4. Are you eligible to work in the USA?
 
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5. Legal FIRST Name:
 
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6. Zip Code:
 
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7. What is your primary phone number?
 
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8. Is it OK to leave a message on your primary phone?
 
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9. What is your secondary phone number?
 
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10. Is it OK to leave a message on your secondary phone?
 
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11. Who do you designate as an emergency contact?
 
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12. What is your emergency contact's phone number?
 
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13. What is your date of birth?
 
   
14. What is your height? (Precise height will be calculated/verified at your first office visit.)
 
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15. What is your current weight in pounds? (Precise weight will be calculated/verified at your first office visit.)
 
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16. What race and/or ethnicity best represents you?
 
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If Multi-Racial or Other, please explain:
17. Please select your highest level of education completed.
 
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18. Have you ever been convicted of a crime?
 
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If yes, for what reason?
19. Have you ever spent time in jail?
 
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If yes, please explain:
20. How many nicotine products (cigarettes, e-cigarettes, nicotine gum, etc.) do you use per week? (Nicotine testing will be completed in the office.)
 
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21. Have you ever used marijuana?
 
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22. Have you ever used other recreational drugs such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetamines, Hallucinogens, Tranquilizers (non-medical), PCP, Inhalants, Steroids (non-medical), Ecstacy, or other recreational drugs for NON-MEDICAL purposes?
 
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Please list the name(s) of any/all recreational drug(s) used within the time frame selected above:
23. How many alcoholic drinks do you usually consume in a week?
 
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24. Have you ever been excluded from donating blood?
 
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If yes, please identify the reason for the exclusion and dates:
25. Have you ever received any type of fertility treatment?
 
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If yes, when and on what basis?
26. Do you have both ovaries?
 
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27. Have you previously applied to be a donor with our program?
 
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If yes, please provide additional information.
28. How many total egg donation cycles have you completed in the past?
 
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29. What method of birth control are you CURRENTLY using?
 
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30. At what age did your menstrual periods begin?
 
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31. Are your menstrual periods regular (24-36 days)?
 
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32. How many total pregnancies have you had?
 
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33. Have you been diagnosed with Chlamydia or Gonorrhea within the last year?
 
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34. FDA - Have you injected drugs for a non-medical reason in the past 5 years, including intravenous, intramuscular, or subcutaneous injection?
 
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Please Explain
35. FDA - Have you engaged in sex in exchange for money or drugs in the preceding 5 years?
 
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Please Explain
36. FDA - Have you had sex in the preceding 12 months with any person who would have answered yes to any of the 3 previous items, or had sex with a male who has had sex with another male in the preceding 5 years, or with any person known or suspected to have HIV infection, including any person who has had a positive or reactive test for HIV virus, hepatitis B (HBV) infection or clinically active (symptomatic) hepatitis C (HCV) infection?
 
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Please Explain
37. FDA - Have you been exposed in the preceding 12 months to known or suspected HIV, HBV, and/or HCV-infected blood through percutaneous inoculation (e.g., needle-stick) or through contact with an open wound, non-intact skin, or mucous membrane?
 
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Please Explain
38. FDA - Within the preceding 12 months, have you undergone tattooing, ear piercing, or body piercing in which sterile procedures were not used e.g. contaminated instruments and/or ink were used, or shared instruments that had not been sterilized between procedures were used?
 
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Please Explain
39. FDA - Have you been treated for or had syphilis within the preceding 12 months?
 
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Please Explain
40. FDA - Have you been treated for or had Chlamydia trachomatis or Neisseria gonorrhea infection in the preceding 12 months?
 
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Please Explain
41. FDA- Have you been diagnosed with Zika infection in the past 6 months?
 
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42. FDA - Have you lived in or traveled anywhere outside the continental United States in the past 6 months?
 
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If yes, list all places lived in or traveled to and dates:
43. FDA - Have you had unprotected sex with a male who would answer YES to either of the last 2 questions
 
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44. What is your email address for communication with you regarding your pre-screen application?
   
45. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
46. Verify your password.
   

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