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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
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Florida
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Hawaii
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Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
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Washington D.C.
What category 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
Do you have a history of Lyme disease or any other tick-borne disease?
Yes
No
Do you have any known history of tick bites?
Yes
No
Are you pregnant or lactating?
Yes
No
Not Applicable (for males only)
Do you feel comfortable having ticks feed on you for a few days? These are clean laboratory-bred ticks that have tested negative for all known infections to cause disease in humans.
Yes
No
Do you live within 50 miles of NIH Clinical Center at Bethesda, MD and able to participate for 11 in-person outpatient visits over the course of 5-7 months?
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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BCFS00587
