Skip to content
Screening Form
Please complete the screening form below
First Name
Hide on Form
Last Name
Hide on Form
Phone Number
Email Address
Gender
Show on Form
Male
Female
Date of Birth
Show on Form
What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
What is your zip code?
What 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
Which of the following best describes you?
Father
Mother
Other parental role
Not a parent
How many children do you have under the age of 2?
Select
0
1
2
3
What month was your child (under the age of 2) born?
January
February
March
April
May
June
July
August
September
October
November
December
What year was your child (under the age of 2) born?
2022
2023
2024
What month was your older child under the age of 2 born?
January
February
March
April
May
June
July
August
September
October
November
December
What year was your older child (under the age of 2) born?
2022
2023
2024
What month was your younger child (under the age of 2) born?
January
February
March
April
May
June
July
August
September
October
November
December
What year was your younger child (under the age of 2) born?
2022
2023
2024
What month was your oldest child (under the age of 2) born?
January
February
March
April
May
June
July
August
September
October
November
December
What year was your oldest child (under the age of 2) born?
2022
2023
2024
What month was your second child (under the age of 2) born?
January
February
March
April
May
June
July
August
September
October
November
December
What year was your second child (under the age of 2) born?
2022
2023
2024
What month was your youngest child (under the age of 2) born?
January
February
March
April
May
June
July
August
September
October
November
December
What year was your youngest child (under the age of 2) born?
2022
2023
2024
How many days a week does your child live with you?
Select
0-1 days
2-4 days
5-6 days
Every day
Do you own a smartphone?
Yes
No
Do you read and speak English?
Yes
No
Do you read and speak Spanish?
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.
Captcha
Hide on Form
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00775
