Application

Contact Information

To expedite the prescreen process, please upload a photo of yourself. Please make sure that your entire face is visible - no sunglasses or hats, please.

Your Physical Attributes

Select a maximum of five (5) ethnicities. Hold the Control Key (Option Key on Mac) while clicking to add/remove additional selections. If you do not see your ethicity listed, please add it to the comments below.
Note: Please be specific (not Caucasian, European, Asian, etc.)

AdoptedAfrican AmericanAlbanianAmerican IndianAmerican Indian - CherokeeArmenianAustrianAustralianBasqueBohemianBrazilianBritishBurmeseCambodianCanadianChamorroChineseColombian ColombianCosta RicanCreoleCubanCzechDanishDutchEcuadorianEgyptianEnglishEthiopianFilipinoFinnishFrenchGermanGreekGuatemalanHawaiianHispanicHmongHungarianIndianIranianIraqiIrishItalianJamaicanJapaneseJewishKenyanKoreanLaotianLebaneseLithuanianMestizo-South AmericanMexicanMiddle EasternNepalNicaraguanNigerianNorwegianPakistaniPanamanianPersianPolishPortuguesePuerto RicanRomanianRussianSamoanScandinavianScottishSerbianSlovakianSlovenianSpanishSwedishSwissTaiwaneseTurkishUkrainianVietnameseVirgin IslanderWelshOther (listed below)

Additional Information

Family History:

Your Comments:

Required Questions

FDA regulations require that we ask you the following questions. Your complete honesty and accuracy are essential & appreciated. A "Yes" answer to any of the following questions will not necessarily disqualify you.

In the past 12 months, have you had a blood transfusion?YesNo

Have you ever had a blood transfusion in England, Wales, Scotland, Northern Ireland, Channel Islands, Isle of Man, Gibraltar or Falkland Islands?YesNo

In the past 12 months, have you had sex with any person who has ever received human-derived clotting factor concentrates?YesNo

Have you ever received human pituitary-derived growth hormone or beef-derived insulin?YesNo

In the past 12 months, have you had any tissue transplantation or ever had a transplantation of cornea (covering of the eye) or dura mater (covering of the brain)?YesNo

Have you or any of your blood relatives ever had Creutzfeldt-Jakob disease or been told you are at risk for it?YesNo

In the past 5 years, have you used injectable (I.V.) drugs for non-medical purposes?YesNo

In the past 12 months, have you had sex with someone who has used I.V. drugs?YesNo

In the past 12 months, have you had sex with a man who has had sex with another man?YesNo

In the past 12 months, have you had sex with any person known or suspected to have HIV infection, clinically active Hepatitis B infection or Hepatitis C infection?YesNo

In the past 6 months, how many sexual partners have you had?

In the past 5 years, have you ever had sex for money or drugs?
YesNo

In the past 12 months, have you been exposed to known or suspected HIV, Hepatitis B, and/or Hepatitis C through infected blood by inoculation (i.e., needle stick) or through contact with an open wound or mucous membrane such as eye or mouth?YesNo

In the past 12 months, have you been held in jail, prison or correctional facility for more than 72 hours?YesNo

In the past 12 months, have you had any body piercings, ear piercings, tattoos, or acupuncture in which shared instruments are known to have been used?YesNo

Have you ever been diagnosed with clinical, symptomatic or viral Hepatitis?YesNo

In the past 2 months, have you had a smallpox vaccination or have you had contact with the smallpox vaccination site of another person?YesNo

In the past month, have you had direct contact with a person with or suspected to have SARS or West Nile Virus?YesNo

In the past 7 days, have you had a fever with a headache?
YesNo

In the past 14 days, have you had an open sore or infection?
YesNo

Have you, your partner or any member of your household ever had a transplant or medical procedure that involved being exposed to lives cells, tissues or organs from an animal?YesNo

I understand that I must not have any vaccination within one month of egg/sperm donation.YesNo

In the past 28 days, have you had a temperature >100.4, cough, shortness of breath, difficulty breathing, hypoxia or x-rays, indicating pneumonia or acute respiratory distress syndrome?YesNo