Reproductive Science Center Bay
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. FIRST name
 
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4. City
 
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5. What is your state of residence?
 
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6. Zip
 
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7. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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8. In which country were you born?
 
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Other: please provide country of birth
9. What is your date of birth?
 
   
10. Is your work schedule flexible?
 
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11. Have you applied or been screened to be an egg donor before?
 
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12. How many times have you donated?
 
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13. Are you currently enrolled as an egg donor in another program?
 
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14. Are you adopted?
 
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Please Explain
15. Height - before entering your height, please measure yourself. It is important that this is accurate and not an estimate
 
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16. Weight - before entering your weight, please weigh yourself. It is important that this is accurate and not an estimate
 
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17. Which best describes your level of education?
 
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Please Explain-- (High School diploma, Associates, Bachelors, Masters, Doctorate, Other, etc...)
18. Closest description of your race
 
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If multi-racial, please provide your closest description.
19. How many cigarettes do you smoke per day?
 
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20. Have you ever used any of the following recreational drugs for non-medical reasons: (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids
 
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If yes, which one(s) and when did you last use them?
21. How many alcoholic drinks do you usually consume in a week?
 
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22. Do you have both ovaries?
 
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23. Are your currently breastfeeding?
 
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24. Has your fertility even been evaluated by a fertility specialist, or, have you ever been told you were infertile by a medical professional?
 
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If yes, when and why?
25. What is/are your reasons for wanting to donate eggs?
 
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26. What resources influenced or supported your decision to apply to donate your eggs?
 











Please help us by providing any additional detail.
27. What is your email address for communication with you regarding your pre-screen application?
   
27. Please verify your email address
   
28. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
29. Verify your password