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Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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First Name
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What sex were you assigned at birth? (biological sex)
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Other
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Date of Birth
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What city do you live in?
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What state do you live in?
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What county do you live in?
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Select all of the following that best describes you:
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
What tobacco products have you used in the last 30 days? Select all that apply.
Moist Snuff
Snus
Chewing tobacco
Cigarettes
E-cigarettes
Nicotine pouches
Cigars
Other
None of the above
Please explain:
About how cans of moist snuff do you use each week?
.5
1.5
2
2.5
3+
How long have you used moist snuff at this frequency?
Less than 6 months
6 months or longer
Do you have reliable transportation to visit the Ohio State lab in Columbus for 5 study visits?
Yes
No
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinicals Terms of Service and Privacy Policy for more information.
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