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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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Age
Birth year
Are you a U.S resident?
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What is your street address?
What city do you live in?
What state do you live in?
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Alabama
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What is your zip code?
What categories best describe 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 is your gender identity?
Man
Woman
Trans Man
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Genderqueer/Gender non-conforming
Prefer to self-identify
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Do you speak English?
Yes
No
Have you consumed alcohol on average two or more times per week over the last 3 months?
Yes
No
What kind of smartphone do you own?
iPhone
Android
Other
If you have an iPhone, please indicate whether the iOS version is 13 or newer. To find this on your phone: Go to “Settings”, Click “General”, Click “About”, Find “iOS Version”
My iOS version is older than 13
My iOS version is 13 or newer
If you have an Android, please indicate whether the version is 10 or newer. To find this on your phone: Go to “Settings”, Click “About phone” Scroll down to “Device details” section Find “Android version”
My Android version is older than 10
My Android version is 10 or newer
Are you willing to engage in Ecological Momentary Assessment activities as part of our study? This involves completing brief survey assessments related to alcohol use and racial discrimination a few times per day on your smartphone if you are eligible.
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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BCFS00594
