BCFS00714-UMN-TervoClemmens-CannabisUseDisorder [Screening Form-Teens] -

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Screening Form

Please complete the screening form below

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First Name

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Last Name

Phone Number

Email Address

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Gender native

Male

Female

Biological sex at birth

Female

Male

Intersex

Other

If “other”, please specify

Gender

Female

Male

Non-binary

Transgender female

Transgender male

Other

If other, please specify

Pronouns

She/her

He/him

They/them

Other

If “other”, please specify.

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Date of Birth

For the next three answers, please complete the information for where you will be located for the next three months.

City of residence for the next three months

Zip code of city

State of residence for the next 3 months

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

Please indicate your age

Under 15

15-17

18

19 or older

Do you think your parent or guardian would be willing to provide written informed consent of your participation in this study?

Yes

No

Maybe

Not sure

Before we can contact you about the study, we must briefly speak with your parent or guardian and receive their permission to move forward. Please provide their contact information below. Parent/guardian name (first and last).

Parent/guardian email

Parent/guardian phone number

Best time to contact parent or guardian

8:00am-11:00am

11:00am-2:00pm

2:00pm-5:00pm

On average, how many days per week do you use cannabis/marijuana?

Every day

4-6 days per week

1-3 days per week

Never

Do you currently take any antipsychotic medications?

Yes

No

How often do you smoke cigarettes or vape e-cigs?

Never

Sometimes

Daily

What is the best time of day to contact you?

8:00am-11:00am

11:00am-2:00pm

2:00pm-5:00pm

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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Tagged BCFS00714