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 Code
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4. How far away from our Tampa office do you live?
 
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5. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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6. What is your height?
 
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7. What is your weight?
 
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8. What is your date of birth?
 
   
9. What race would you most likely be affiliated?
 
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Please Explain
10. Which best describes your level of education?
 
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11. If you are currently in college, what year?
 
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What is your major?
12. Are you a US citizen or permanent resident?
 
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13. Are you eligible to work in the United States?
 
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14. Is your work / school schedule flexible?
 
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Please provide times when you definitely are not available.
15. Are you adopted?
 
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16. In which country were you born?
 
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17. Have you spent 3 months or more cumulative in the United Kingdom from 1980 through 1996?
 
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Please Explain
18. 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
19. Have you spent 5 or more years cumulative in Europe?
 
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Please Explain
20. Have you had any serious illness in the past?
 
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If yes, describe.
21. Have you traveled or lived in an area with active ZIKV transmission within the last 6 months according to the CDC ZIKA travel notices?
 
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22. Have you had a medical diagnosis of ZIKV infections in the last 6 months?
 
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23. Do you have both ovaries?
 
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24. Have you had sex in the last 6 months with a male who is known to either have a diagnosis of ZIKV infection, has lived in or traveled to an area with active ZIKV transmission within the last 6 months?
 
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25. What kind of contraception do you use?
 
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Please describe the IUD type
26. Have you ever been told you were infertile?
 
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If yes, when and why?
27. List all prescription medications that you have taken in the proceeding 12 months. (enter "None" in the first box if you haven't taken any prescription medications)
 
Medications Medication How Often Reason
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2:      
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28. How many cigarettes do you smoke per day?
 
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29. How many drinks do you usually consume in a week?
 
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30. Have you ever 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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If yes, which one(s) and when did you last use them?
31. Have you had acupuncture, ear and/or body piercings or tattooing on your body?
 
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If yes, please provide details.
32. How many times have you donated?
 
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33. Are you currently enrolled as an egg donor in another program?
 
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34. What resources have influenced your decision to apply?
 









Please provide which website, radio station, newspaper or person who referred you.
35. I understand that the results of this pre-screen will be sent to me from no-reply@donorapplication.com. I understand this email must be accepted by my spam filters.
 
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36. I understand that this is the pre-screen application. If approved, I will receive an email from no-reply@donorapplication.com with a link. Additionally, if approved, the email address I enter below and the password I select will become active so I can complete the rest of the application.
 
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37. What is your email address for communication with you regarding your pre-screen application?
   
38. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
39. Verify your password.
   

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