1. FIRST name
 
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2. Have you ever injected drugs or had a sexual partner who did so?
 
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Why type of drug was injected? Why was this drug used?
3. In the past 12 months, have you been exposed ot, tested positive, been diagnosed or traveled to an area active with either the Ebola virus or Zika Virus?
 
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4. LAST name
 
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5. Street address? (include apartment if approprate)
 
---> Street Address Apartment City State Zip
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6. Within the past 12 months have you, anyone you live with, have close contact with or are intimate with:
 

It is very important that you explain in detail anything referenced above.
7. Mobile Number
 
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8. 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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9. What is the easiest way to contact you?
 










What are the best times to contact you?
10. been diagnosed with any form of hepatitis?
 
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11. Country of Residence
 
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If "Other", please provide the name of the country.
12. Within the past 12 months, have you, anyone in your household or any of your close contacts, ever lived with (resided in the same dwelling) or been intimate with another person who has Hepatits B or clinically active (symptomatic) Hepatitis C infection?
 
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13. 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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14. Have you had a past diagnosis of clinical, symptomatic viral hepatitis after your eleventh birthday, unless evidence from the time of illness documents that the hepatitis was identified as being caused by hepatitis A virus (e.g., a reactive IgM anti-HAV test), Epstein-Barr Virus (EBV), or cytomegalovirus (CMV)?
 
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15. Have you or any of your close contacts had a smallpox vaccine within the past 8 weeks?
 
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16. If you have had a smallpox vaccination (vaccinia virus) in the preceding 8 weeks, has it been 21 days post-vaccination?
 
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17. Please select the best answer related to smoking and tobacco use (including any form of nicotine products, including e-cigarettes, Hookah, Nicotine patch, chewing tobacco)
 
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Please explain for how long you smoked or used tobacco, at what age, how long ago did you quit
18. What is your date of birth?
 
   
19. Have you tested positive or reactive for WNV infection using an FDA-licensed or investigational WNV NAT donor screening test in the preceding 120 days?
 
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20. Have you traveled to a Zika infested area or been infected with Zika Virus within the past 12 months?
 
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If Yes, Please Explain:
21. Have you been treated for or had syphilis within the preceding 12 months?
 
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22. Height
 
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23. Weight
 
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24. Is there anything in your history, the history of someone with whom you have been intimate, or with whom you live with, related to:
 










It is very important that you explain in detail anything referenced above.
25. Have you or any of your blood relatives ever been diagnosed with Creutzfeldt-Jakob disease (CJD)?
 
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26. Do you have hemophilia or other related clotting disorders and have received human-derived clotting factor concentrates in the preceding five years, not including receiving clotting factors once to treat an acute bleeding event more than 12 months ago?
 
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27. Is there anything in your history or the history of someone with whom you have been intimate, who has ever:
 












It is very important to explain in detail any item referenced above.
28. Have you ever been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system or other neurological disease of unknown etiology?
 
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29. Have you received a non-synthetic dura matter transplant, received human pituitary derived growth hormone, and/or have one or more blood relatives diagnosed with CJD that was not subsequently found to be an incorrect diagnosis, found to be iatrogenic, or that laboratory testing (gene sequencing) shows that you do not have a mutation associated with CJD?
 
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30. Have you spent 3 months or more, cumulatively, in the UK (England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands) from the beginning of 1980 through the end of 1996?
 
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31. Which of the following have you had?
 










It is very important that you explain in detail anything referenced above.
32. Have you lived cumulatively for 5 years or more in Europe (Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, England, Northern Ireland, Scotland, Wales, Isle of Man, Channel Islands, Gibraltar, Falkland Islands, and Yugoslavia) from 1980 until present?
 
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33. Have you, in the last 12 months, been diagnosed with sepsis (including bacteremia, septicemia, sepsis syndrome, systemic infection, systemic inflammatory response syndrome (SIRS) or septic shock)?
 
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34. Have you ever had clinical evidence of infection with two or more of the following systemic responses to infection if unexplained: temperature of greater than 100.4 degrees Fahrenheit (38 degrees Celsius), elevated heart rate, elevated respiratory rate or elevated white blood cell count?
 
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35. Have you, in the past 12 months, experienced more severe signs of sepsis including unexplained hypoxemia, elevated lactate, oliguria (less than normal urination), altered mentation and hypotension (low blood pressure)?
 
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36. Have you, in the last 12 months, had a blood test that resulted in a positive blood cultures associated with the conditions in the previous question?
 
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37. Have you ever been diagnosed with adult T-cell leukemia?
 
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38. What is your email address for communication with you regarding your pre-screen application?
   
39. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
40. Verify your password.
   

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