BuildClinical | Customer Preview

Screening Form

Please fill out this form. If you're filling it out for someone else (e.g., your child, your loved one), answer the "Participant" questions about them.

Relationship to the participant:

Self

Parent/Guardian

Caregiver

Loved One

Other

Other:

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Participant's First Name

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Participant's Last Name

What is the participant's preferred name?

Parent or Guardian's First Name

Parent or Guardian's Last Name

What is the participant's best phone number to reach?

Allowed Countries:

What is the participant's best email address to reach?

What is the parent or guradian's best phone number to reach?

What is the parent or guardian's best email address to reach?

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Participant's Gender

Male

Female

Other

Participant's Preferred Pronouns

She/her

He/him

They/them

ze/zem

Not Listed

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Participant's Date of Birth

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What city does the participant live in?

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What state does the participant live in?

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Select all of the following that best describes the participant:

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

Is the participant currently enrolled in grades 7-12?

Yes

Does the participant use social media on a daily basis?

Yes

Does the participant have a smartphone that can download apps?

Yes

What is the participant's best method to contact?

Call

Text

What is the parent or guardian's best method to contact?

Call

Text

What is the best time of day to contact you?

Early Morning (9AM-10AM)

Late Morning (10AM-12PM)

Early Afternoon (12PM-3PM)

Late Afternoon (3PM-5PM)

Evening (5PM-7PM)

You agree that BuildClinical may provide your personal information to the research team conducting this study to determine whether you are eligible for study participation. BuildClinical may also use your information to inform you about other research opportunities that may be relevant to you. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.

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Customer Preview

Screening Form

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Eligibility Criteria:

The eligibility criteria listed here is only visible in the Customer Preview version of the form. Eligibility will not be visible for potential participants filling out the form.

Customer Preview

Screening Form

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Eligibility Criteria:

The eligibility criteria listed here is only visible in the Customer Preview version of the form. Eligibility will not be visible for potential participants filling out the form.