COMMUNITY SCREENING EVENT PARTICIPANT INTAKE FORM Date(Required) MM slash DD slash YYYY PARTICIPANT CONTACT INFORMATIONFirst Name:(Required) Last Name:(Required) Middle Initial: Zip Code:(Required) Main Telephone Number:(Required) Email Address:(Required) Date of Birth:(Required) MM slash DD slash YYYY Age:Sex(Required)MaleFemaleRace(Required)CaucasianBlack/African AmericanAsianNative American/Alaska NativeHawaiian / Other Pacific IslanderOtherEthnicity:(Required)Hispanic / LatinoNon-Hispanic / LatinoPrimary Language:EnglishSpanishOtherCOMMUNITY SCREENING EVENT GENERAL INFORMATIONAre you currently enrolled in a clinical trial?(Required)YesNoNot SureIf yes, Please list: Disclaimer(Required) I agree Consent*(Required) I agree Disclaimer: By answering this form, you acknowledge and consent to being contacted by our clinical research team. The purpose of this contact is to discuss your responses further, gather additional information if necessary, and provide any relevant updates or opportunities related to the clinical research being conducted. Completion of this form does not guarantee access to participate in any clinical trials. Rest assured that your personal information, including any sensitive or protected health information, will be handled with the utmost confidentiality and in compliance with applicable laws and regulations. Δ