IVF Clinical Trial

Contact Information

First Name:
Middle Name:
Last Name:
Address:	Apt #:
City:	State
		Zip:
Home Phone:	Work Phone:	Ext:
** Please use digits only for phone numbers, i.e. (212) 517-7676 would be 2125177676.
Cell Phone:	Preferred Phone:
Email Address:	Confirm Email:
** A valid email address is required. An application without a verified email address will NOT be processed.
Enter Code:

Note: Any identifiable information that is obtained in connection with this study will remain confidential and will be disclosed only with your permission or as required by law. Your name will be kept separate from your record. Only the researchers will know of your participation in this study.

Partner's Contact Informtaion

First Name:
Middle Name:
Last Name:
Address:		Apt #:
City:		State
			Zip:
Home Phone:		Work Phone:	Ext:
	Please use digits only for phone numbers, i.e. (212) 517-7676 would be 2125177676.
Cell Phone:		Preferred Phone:
Email Address:		Confirm Email:

Have you ever participated in a Medical Research study before?	Yes No
Have you been trying to conceive for at least 12 months?	Yes No
Have you previously tried in vitro fertilization treatment (IVF)?	Yes No
This study will take approximately six months (including 20 Clinic visits performed in New York City). Do you think you will be able to participate for the whole length of the study and NOT drop out?	Yes No
Do you have easy access to the internet and think you will be able to go on line everyday at the beginning of the study and answer questions in your daily log regarding your daily experiences?	Yes No

Gender at birth	Male Female
Date of Birth:

Place of birth:	Country:
	State/Provice:
	City/Town:

Primary Ethnicity	Asian Black Caucasian Hispanic/Latino Other:
Height:	ft. in.
Weight:	lbs.

What is the highest level of education you have completed?	High School Some College (no degree) College (Bachelor's degree) Graduate School
What is your total household income?	Under $40,000 $40,000 - $80,000 (no degree) $80,000 - $120,000 $120,000 or more
What is the number of adults in your household?	1 2 3 More:
What is the number of children in your household?	0 1 2 More:
How many languages are you fluent in?	1 2 3 More

Which of these religious categories best describes you?	Buddhist Catholic Hindu Jewish Muslim Protestant None Other
How would you describe your current level of religious or spiritual involvement?	None Low Moderate High

Partner's gender at birth	Male Female
Date of Birth:
Partner's Ethnicity	Asian Black Caucasian Hispanic/Latino Other:

Eligibility

Confidentiality

How did you FIRST hear about our study?

Online (Click to see options)

Referral (Click to see options)

Print Source (Click to see options)

Basic Questions

What is your reason for treatment?

What is your primary motivation for participating in this study?

Primary Demographics (please fill out for FEMALE partner)

Partner Demographics (please fill out for MALE partner)

Contact Information

Partner's Contact Informtaion

Pre-screening Quiz