Hello! Please fill out the form below to help us determine if you may be eligible to participate in one of our studies. If you are eligible, we will follow up with you directly!
Research Eligibility Screening Form
Name
*
Name
First
First
Last
Last
Email
*
Phone
*
Current Age
*
Are you Latino/Latina or Hispanic?
*
Please select
Yes
No
What’s your primary race/ethnicity?
*
Please select
Black/African American
White/Caucasian
East Asian
South Asian
Native American/Indian American
Pacific Islander/Native Hawaiian
Mixed Race
What state do you currently live in?
*
What city do you currently live in?
*
What is your current zip code?
*
How long have you lived in your current zip code?
*
Please select
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
10 months
11 months
1 year
2 years
3 years
4 years
5 or more years
Which days of the week would be best for you to participate in our study? Please select all that apply.
*
Sundays
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Which times of the day would be best for you to participate in our study? Please select all that apply.
*
Mornings
Afternoons
Evenings
If you are human, leave this field blank.
Submit