Thank you for your interest in donating eggs to infertile couples who desire to have a family of their own. This is the first step in the process. Many donors will not be eligible to continue in the process because they do not meet federal donation criteria. These questions are designed to keep potential donors from spending too much time on this process if they cannot be accepted. There can be no guarantee that even if your answers are acceptable, you will be able qualify during the remaining screening process. Please answer honestly. Thank you again for your time and interest in our program.
1. What is your FIRST name?
 
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2. What is your LAST name?
 
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3. What is your mailing address?
 
Address Street Address City State Zip/Postal Code Country
Address:          
4. What is the primary phone number to use for contact and leaving messages? (e.g. 555-555-5555 ... remember to include the area code)
 
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5. What is your date of birth?
 
   
6. Are you a US citizen or permanent resident?
 
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7. Are you eligible to work in the United States?
 
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8. Have you applied or been screened to be an egg donor before? If yes, provide the name and location of the donor program(s) and whether you are currently an active donor for them.
 
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Please Explain
9. Are you currently enrolled as an egg donor in another program?
 
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10. How many times have you donated?
 
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11. Are you currently under a physicians care for any reason? If yes, a detailed explanation is required.
 
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Please Explain
12. Have you ever had any major illnesses such as ameobic dysentery (infection of the intestine), hypertension, blood clots, pneumonia, mononucleosis, etc.? If yes, when? A detailed explanation is required.
 
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Please Explain
13. Have you had any serious illness in the past? If yes, describe. A detailed explanation is required.
 
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Please Explain
14. During the last 12 months, have you been exposed to known or suspected HIV, HBV, and/or HCV infected blood through a needle-stick or contact with an open wound or mucous membrane of an infected person?
 
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15. Have you been diagnosed with viral hepatitis B or C after age 11?
 
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16. During the last 12 months, have you had close contact (living in the same household) with someone having clincially active viral hepatitis?
 
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17. During the last 12 months, have you had or been treated for Chlamydia, Gonorrhea, or Syphilis?
 
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18. Do you have allergies?
 
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19. Have you ever had a diagnosis of vCJD or any CJD, Dementia or any degenerative or demyelinating disease of the Central Nervous System or other neurological disease?
 
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20. Have you ever taken human pituitary-derived growth hormone or received a non-synthetic dura mater transplant or been the recipient of a xenotransplantation product or had a medical procedure that exposed you to live cells, tissues or organs of an animal?
 
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21. List all medications that you have taken in the proceeding 12 months (prescription)
 
Medications Medication How Often Reason
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22. List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.).
 
OTC Medications Medication How Often Reason
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23. Have you had a blood transfusion? If yes, you must provide information regarding when and for what reason?
 
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Please Explain
24. Have you ever been refused or denied as a blood donor? If yes, you must provide a detailed explanation of the reason.
 
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Please Explain
25. Have you ever been exposed to "agent orange" or any other herbicides or chemicals (military, forestry, highway service or elsewhere)? If yes, which substance(s), when and where?
 
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Please Explain
26. Have you ever lived or traveled outside the US for more than 3 months since 1980 and if so where?
 
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27. Describe any major illnesses in family members and which family members were affected.
 
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28. What is your caffeine usage?
 
Caffeine Cups/Day
Coffee:  
Soda:  
Tea:  
Energy Drinks:  
Other:  
29. Do you currently smoke cigarettes?
 
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30. How many cigarettes do you smoke per day?
 
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31. What best describes your alcohol consumption?
 
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32. Have you ever used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)? If yes, which one(s) and when did you last use them? A detailed explanation is required.
 
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Please Explain
33. Have you had acupuncture, ear and/or body piercing or tattooing in the last 12 months in which sterile procedures MAY NOT HAVE been used?
 
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34. Have you ever been incarcerated? If yes, please provide details. We are unable to accept anyone who has been incarcerated for more than 72 hours in the past 12 months.
 
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Please Explain
35. How many pregnancies have you had?
 
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36. How many children have you given birth to?
 
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37. What kind of contraception do you use?
 
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38. What is your height?
 
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39. What is your weight?
 
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40. Are you adopted?
 
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41. What race would you most likely be affiliated?
 
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Please Explain
42. What is the ethnic origin of your mother? (e.g. French, Irish)
 
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43. What is the ethnic origin of your father? (e.g. French, Irish)
 
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44. Which best describes your level of education?
 
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45. Please enter your educational degree(s) or degree(s) you are pursuing in the appropriate year you have completed. (If none, enter "none").
 
Degrees Associates Bachelor Masters Ph.D.
Year 1:        
Year 2:        
Year 3:        
Year 4:        
Completed:        
46. What is/are your reasons for wanting to donate eggs?
 
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47. How did you hear about our program? Please provide which website, radio station, newspaper or magazine.
 
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Please Explain
48. What is your email address for communication with you regarding your pre-screen application?
   
49. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
50. Verify your password.
   

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