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1.

In the past 5 years, have you had sexual contact with a man who has had sexual contact, either anal or oral, with another man? *

2.

Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular, or subcutaneous injection? *

3.

Are you eligible to work in the United States? *

4.

Are you a US citizen or permanent resident? *

5.

Have you ever been diagnosed with hemophilia or a related clotting disorder for which you have received human-derived clotting factor concentration? *

6.

Have you had sex for drugs or money in the past 5 years? *

7.

FIRST name *

8.

LAST name *

9.

In the past 12 months, have you given money or drugs to anyone to have sex with you? *

10.

Street address? (include apartment if approprate) *

11.

In the past 12 months have you had sex with nay person who has injected drugs for a non-medical reason, been diagnosed with hemophilia or a related clotting disorder and received human-derived clotting factor concentrates, or who has HIV infection, Hepatitis B infection or a clinically active Hepatitis C infection? *

12.

In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B, and/or hepatitis C infected blood through percutaneous inoculation (needle stick), or through contact with an open wound or mucous membrane? *

13.

City *

14.

State *

15.

In the past 12 months, have you been incarcerated in a lock-up, jail or prison for more than 72 hours? *

16.

In the past 12 months, have you been in close contact (i.e. sharing kitchen and bathroom) with a person with Hepatitis B or clinically active Hepatitis C or any viral Hepatitis? *

17.

Zip Code *

18.

Primary Phone Number *

19.

In the past 12 months, have you had tattooing, ear or body piercing in which sterile procedures were not used, e.g. shared instruments, contaminated ink, or instruments that were not sterilized prior to use? *

20.

Since age 11 have you had a past diagnosis of clinical, symptomatic viral hepatitis? *

21.

Text friendly cell phone number (enter N/A if you don't have a text friendly phone or capability, otherwise enter the actual number) *

22.

Date of Birth *

23.

In which country were you born? *

24.

Are you adopted? *

25.

Have you ever had a medical diagnosis, or suspicion of West Nile Virus? *

26.

In the past 12 months have you been treated for or had syphilis? *

27.

What race do most people consider you to be? *

28.

Height *

29.

In the past 12 months, have you been treated for Gonorrhea or Chlamydia? *

30.

Weight *

31.

Have you or any of your relatives or acquaintances had Creutzfeldt-Jacob (Mad Cow) disease? *

32.

What is your highest level of completed education? *

33.

Is your work schedule flexible? *

34.

Have you been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system, or any other neurological disease of unknown case? *

35.

Are you currently enrolled as an egg donor in another program? *

36.

Have you ever received a non-synthetic dura mater (brain covering) transplant? *

37.

How many times have you donated your eggs? *

38.

Have you ever received growth hormone made from human pituitary glands? *

39.

Have any of your blood relatives ever had Creutzfeldt-Jakob disease? *

40.

Do you have both ovaries? *

41.

Are your currently breastfeeding? *

42.

From the beginning of 1980 through the end of 1996 did you spend time that adds up to 3 months or more in the United Kingdom? (Includes England, Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar and the Falkland Islands) *

43.

Are you a current or former US military member, civilian military employee, or dependent of a military member or civilian employee who resided at U.S. military bases in Northern Europe (Germany, Belgium, and the Netherlands) for 6 months or more from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal or Italy) from 1980 through 1996? *

44.

Have you ever been told you were infertile? *

45.

Have you lived cumulatively for 5 years or more in Europe from 1980 until the present? (Includes Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland and Yugoslavia) *

46.

Have you had sexual contact with anyone who was born or lived in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria after 1977? *

47.

Were you born in, or have you lived in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria since 1977? *

48.

Since 1977 have you ever had a blood transfusion or any medical treatment that involved blood in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria? *

49.

Have you ever been refused or denied as a blood donor? *

50.

Have you been in a place affected by SARS or with an affected person within the past 14 days? *

51.

Have you had close contact with someone who has traveled to or resided in areas affected by SARS in the last 14 days? *

52.

Have you been treated for SARS in the last 28 days? *

53.

Have you had close contact within the previous 14 days with persons with SARS or suspected SARS? *

54.

Have you ever used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)? *

55.

How may brothers, sisters & parents in your family have a history of alcohol or drug abuse? *

56.

Have you had a medical diagnosis of the ZIKA virus in the past 6 months? *

57.

Have you had sex within the last 6 months with a male who had a medical diagnosis of Zika Virus in the past 6 months? *

58.

Have you had ear and/or body piercings or tattooing on your body? *

59.

Do you drink alcoholic beverages? *

60.

How many drinks do you usually consume in a week? *

61.

Have you received any transfusion of blood or blood components in the U.K. or France between 1980 and the present? *

62.

How many cigarettes do you smoke per day? *

63.

Why do you want to become a donor? *

64.

I understand that receiving egg donor compensation may jeopardize my eligibility for certain government programs, including but not limited to Medicaid, Care Source and Amerigroup insurance for myself and my family. I further understand that it is my responsibility to understand my health insurance benefits and how any compensation may affect my eligibility for these programs. *

65.

Do you have Medicaid, CareSource or Amerigroup medical insurance? *


What is your email address for communication with you regarding your pre-screen application?
(6-20 characters with 4 or more letters and 1 or more numbers)
(Must match)