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Screening Form
Please complete the screening form below
First Name
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Date of Birth
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What category best describes you?
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Please indicate your sex.
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Are you in generally good health?
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Have you ever tested positive for HIV, Hepatitis B, or Hepatitis C?
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(Women only) Are you pregnant, breastfeeding, or planning to become pregnant in the next year?
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N/A
Are you able to commute to the NIH Clinical Center in Bethesda, Maryland and be available in the area for more than 1 year?
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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BCFS00531
