R E A C H
1. Are you eligible to work in the United States?
 
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2. What is your FIRST name?
 
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3. City
 
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4. State
 
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5. What is your date of birth?
 
   
6. What is your height?
 
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7. What is your weight in pounds?
 
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8. Are you currently enrolled as an egg donor in another program?
 
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9. How many times have you donated your eggs?
 
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10. How many cigarettes do you smoke per day?
 
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11. When is the last time you had marijuana?
 
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12. What race would you most likely be affiliated?
 
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Please describe "Other"
13. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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14. When was the last time you have had a tattoo or body piercing?
 
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15. How many current sexual partners do you have?
 
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16. 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?
 
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17. Do you have both ovaries?
 
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18. What was your age at the onset of menses?
 
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19. Are your menstrual periods regular (when not on the pill)?
 
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20. How long is your monthly cycle (first day of one period to first day of the next)?
 
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21. Have you ever been told by a medical doctor that you were infertile and/or conceived with fertility treatments?
 
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If yes, please explain.
22. What is your highest level of completed education?
 
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23. What kind of contraception do you use?
 













If "Other", please explain.
24. FDA-Have you traveled outside of the USA in the last 6 months?
 

25. Is your work schedule flexible?
 
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26. Have you tested positive Chlamydia or Gonorrhea within the last year?
 
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27. Have you ever been refused or denied as a blood donor?
 
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28. Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other medical health professional for any reason?
 
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If yes, when, for how long, for what reason.
29. Are you adopted?
 
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30. Considering only your full-blood relatives, and considering only your grandparents, parents, maternal and paternal aunts and uncles, siblings, self and children, how many people have Alcohol and Drug issues/diseases?
 
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31. Are your currently breastfeeding?
 
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32. Are there known genetic problems in your family?
 
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If yes, please explain.
33. How did you hear about the egg donation program at REACH?
 
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Please explain
34. 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.)"
 
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35. What is your email address for communication with you regarding your pre-screen application?
   
35. Please verify your email address
   
36. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
37. Verify your password