Online Screening Form

Instructions: Please fill out this online form to the best of your ability. Data is stored on a secure server that follows HIPAA guidelines and will remain confidential. All survey information collected will not affect any relationship you may have with the University of Minnesota, and will not be shared with any institution. It will be reviewed by a study staff member and you will be contacted by the phone number you list if we believe you would be eligible to participate in our research study. Thank you.

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