Personal Information | Study Interest Form

Thank you for your interest in CARRII NATIVE WOMEN study and for signing and submitting the Screening Consent Form. Please answer the questions below. Then click COMPLETE. If you meet initial eligibility requirements, we will contact you to discuss possible next steps for being in the CARRII NATIVE WOMEN study. We look forward to talking to you soon! All information you provide will be treated with strict standards of confidentiality. If you do not qualify for the study, your data will be destroyed.

1. What is your name?

First name

Middle name

Last name

2. What is your address?

Street

Apartment

City

State

Zip Code

3. What time zone do you live in? If you are uncertain, make your best guess.

4. What is your date of birth?

5. What is your sex assigned at birth?

Female

Male

Intersex

6. Are you ...?

Hispanic or Latino

Not Hispanic or Latino

7. What is your race?

Check all that apply

Native American

Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

Other, please describe:

8. How did you hear about the CARRII NATIVE Study?