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Healthy Studies Eligibility Questionnaire

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Thank you for your interest in healthy volunteer studies conducted by NIAID's HIV and Emerging Infectious Diseases Program at the National Institutes of Health (NIH) Clinical Center in Bethesda, Maryland.

By filling out this questionnaire, you will be added to a list of potential research study participants. If we have a study for which you may be eligible, our recruiter will call you to explain the study and see if you are interested (note that "Recruitment Office" will appear on your caller ID). Read our clinical trials overview for more information about being a healthy volunteer in NIAID clinical research studies.

This questionnaire is confidential and will not be distributed to any one except the NIAID healthy volunteer study team.

1. What is your birth date? (This will be used to calculate your precise age. Please enter your birth date in this format: MM/DD/YYYY)

2. What is your gender?

3. Are you currently pregnant, breastfeeding, or plan to become pregnant in the near future?

If you are currently pregnant, breastfeeding, or planning to become pregnant in the near future, you are not eligible to participate in our clinical research studies. Please visit www.clinicaltrials.gov for information on other clinical studies for which you may be eligible.

4. Are you available for follow-up study visits for a period of six months to one year?

5. Do you live within 60 miles of the Washington, DC, metropolitan area?

6. Do you have any difficulty having blood drawn (for example, small veins or hard to find veins)?

7. Are you currently taking any prescription medications?

8. Have you previously participated in a clinical research study at NIH?

9. Are you currently participating in a clinical research study at NIH?

10. Are you able to participate in inpatient studies that require you stay at the NIH in Bethesda for several days?

11. Do you currently smoke cigarettes or other tobacco products?

If you would like to receive a call about any study for which you may be eligible, please complete the items below. Your information is strictly confidential.

First name (required)
Last name (required)
Phone number (required)
Email (required)
Best time to reach me
Additional comments
How did you hear about us?
Your answers will be kept confidential and will not be distributed.