Screening Questionnaire

Below is a link to the screening questionnaire for this study. If you are interested in being a study participant, please download, complete, and send the form to Teresa Douglas, Assistant Research Coordinator at

Instructions for Screening Questionnaire

Please fill in Sections A-D without skipping any of the requested information. Also, please fill in the date on the top of the first page. DO NOT fill in the sections that say “Study ID” or “Study Group”. A study team member will review your responses and determine if you meet our eligibility requirements. You will be contacted by a
study team member regarding our decision.