1. Are you a US citizen or permanent resident?
 
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2. Are you eligible to work in the United States?
 
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3. What is your FIRST name?
 
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4. What is your LAST name?
 
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5. What is your mailing address?
 
: Street Address Apartment City State Zip Code
Mailing Address:          
6. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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7. Are we permitted to use this phone number to communicate with you via text?
 
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8. What is your date of birth?
 
   
9. In which country were you born?
 
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10. What is your marital status?
 
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11. Are you adopted?
 
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12. What is your height?
 
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13. What is your current weight? (pounds)
 
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14. What race would you most likely be affiliated?
 
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Please Explain
15. Have you applied or been screened to be an egg donor before?
 
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If yes, provide the name and location of the donor program(s).
16. How many times have you donated?
 
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17. Are you currently enrolled as an egg donor in another program?
 
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18. Which best describes your level of education?
 
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19. Is your work schedule flexible?
 
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Please provide times when you definately are not available.
20. Do you have medical insurance?
 
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21. Do you have both ovaries?
 
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22. Have you ever been told you were infertile?
 
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If yes, when and why?
23. What kind of contraception do you use?
 
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24. Are your menstrual periods regular?
 
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25. How many pregnancies have you had?
 
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26. Are your periods regular when you are not on any type of hormonal birth control such as the pill, etc.?
 
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27. Have you spent 3 months or more cumulative in the United Kingdom from 1980 through 1996?
 
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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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Please Explain
29. Have you spent 5 or more years cumulative in Europe?
 
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Please Explain
30. Are you currently under a physicians care for any reason?
 
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If yes, please explain.
31. List all medications that you have taken in the proceeding 12 months (prescription).
 
Medications Medication How Often Reason
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32. 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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33. Do you have a clotting disorder for which you have received human-derived clotting factor concentration?
 
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Please Explain
34. Have you had a blood transfusion?
 
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If yes, when?
35. After the age of 11, have you ever had viral hepatitis (Hep A excluded: IgM anti-HAV test)?
 
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Please Explain
36. In the past 12 months, have you had tattooing, ear or body piercing in which shared instruments were used?
 
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Please Explain
37. Please list and describe all of your tattooing and body piercings. (Enter "N/A" if you do not have any tattoos or body piercings).
 
Piercings Date Received Description Location on Body Sterile Needles Used?
1:        
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38. How many cigarettes do you smoke per day?
 
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39. How many drinks do you usually consume in a week?
 
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40. Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular, or subcutaneous injection?
 
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Please Explain
41. What resources have influenced your decision to apply?
 








Please provide which website, radio station, newspaper or person who referred you.
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.
   

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