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The value you provided must be within the suggested range.

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^Pro\d{8}$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[1-3]{5}$/

/^[\s\S]{0,50}$/

/^\d{2}.\d$/

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^[A-Z]{2}\d{4,}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

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Series of Questions to Determine if You Can Join the Study

Returning?

A A A

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Date

M-D-Y H:M:S

Cohort Number

Welcome to the screening questions for the Log2Lose study

This study is taking place at the University of Wisconsin Madison (UW-Madison) and Duke University.

The purpose of answering the screening questions is to see if you qualify for this study. These questions make sure that the people who participate in the Log2Lose study are able to do so as safely as possible. Please read these questions carefully and answer them the best you can. Doing so will make sure you can safely participate.

We will ask you to share some personal information, including questions about your past and present health conditions, medications you are taking, and alcohol and drug use. You will need to provide your first and last name, e-mail, age, race, ethnicity, and birth sex. You may also be asked for your complete contact information (address, phone and email) if you would like to be re-contacted about the study in the future.

Your responses will be kept private. Your personal information and responses are stored on secure servers that sit behind a firewall at Duke University. Your information is only available to members on the research team who have approval to view this information.

If you enroll in the study, all information you provide will be securely stored for up to 7 years after the study is complete. If you do not qualify, or decide not to participate, your age, birth sex, race, ethnicity, and information about why you did not qualify or why you declined to participate will be saved for up to 7 years after the study is complete; however, no identifying information such as your name or email address will be kept.

Completing the screening questions and participating in this study are voluntary. You can stop answering any questions at any time. Your refusal to answer questions will not negatively affect any relationship you have with UW-Madison or Duke University.

If you have any questions, please contact the Duke University research team at log2lose@duke.edu or the UW-Madison research team at log2lose@surgery.wisc.edu.

Please select the location that is closest to you:

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North Carolina (Duke University)

Wisconsin (University of Wisconsin-Madison)

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Age

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First Name

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Last Name

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Birth Sex

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Male Female

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How would you describe your race? Please indicate all that apply.

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American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Decline to answer

Do you consider yourself Hispanic or Latino?

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Hispanic or Latino

Not Hispanic or Latino

Decline to answer

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Do you have an email address?

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Yes No

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Email Address
Please note: Your email address will only be used to contact you regarding the Log2Lose study

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How did you find us

* must provide value

Received letter in the mail

Flyer or poster I saw posted in community

Flyer or poster I saw posted at my doctor's office

Received email

Referred by my clinic/doctor

Facebook ad

Instagram ad

Newspaper/newsletter

Saw interview on local news

From friend/family/previous study participant

ClinicalTrials.gov

Other

Where did you see the flyer or poster in your community?

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Which newspaper/newsletter?

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Other

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How did you find us? (select all that apply)

Where?

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Where?

Which one?

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Which publication?

Specify Other

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By checking the box, you are agreeing that you have read all of the information provided above and are willing to proceed with the online screening questions.

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I have read the information and am willing to proceed with the online screening questions.

I have read the information and am NOT willing to proceed with the online screening questions.

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Label

Yes, I am available

No, I am not available

Label

Yes, I am available

No, I am not available

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.