Customer Preview

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

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First Name

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Last Name

Phone Number

Email Address

Are you a parent older than 18 years in the United States?

Yes

If you are the kind of research participant we are looking for, are you willing to upload a picture of your government-issued ID to verify your identity, such as your driver's license or passport? (This is a requirement for us to ensure the quality of our data. Your personal information will be kept confidential.)

Yes

How many biological children between 18-months and 18-years-old do you have?

Is your mother frequently involved with providing care for your child between 18-months and 18-years-old?

Yes

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Gender

Male

Female

Other

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Date of Birth

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What city do you live in?

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What state do you live in?

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Select all of the following that 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

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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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.

If ALL of these conditions are TRUE: