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Screening Form
Please complete the screening form below
First Name
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Last Name
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Phone Number
Email Address
Gender
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Date of Birth
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What city do you live in?
What state do you live in?
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Alabama
Alaska
Arizona
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Florida
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Hawaii
Idaho
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North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
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Washington
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Which category best describes you? (select all that apply)
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
Multiple Races
Other
I Prefer not to Answer
Are you a college student or graduate?
Yes
No
Have you had mono?
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 BuildClinical's Terms of Service and Privacy Policy for more information.
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