M-D-Y
Initials of RA conducting screen
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Date of initial note
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Today M-D-Y
Thank you for your interest in our research studies. The following screening survey is set up to determine if you may qualify for one of our current studies. These questions will take between 5-10 minutes. If we determine that you may qualify, a study staff member will provide you with more detailed information about the study and will ask you some additional questions to determine if you are eligible to complete the screening session. You may also call our lab at 919-907-9955 if you prefer to talk to a staff member directly.
Below is a description of our current study. Please take a minute to read the description.
Would you like to continue with the screening questions?
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Yes, I would like to continue with the screening.
No, I am not interested at this time.
First Name
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Best phone number to reach you
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Best time to reach you during business hours?
Preferred Method of Contact:
Sex assigned at birth
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Female
Male
Intersex/Ambiguous
Which of the following describes how you think of yourself?
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Female or primarily feminine
Male or primarily masculine
Both male and female
Neither male nor female
In another way
What are your preferred pronouns? _____________
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She/Her/hers
He/him/his
They/them/theirs
Other (please specify)
What is your race?
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American Indian, Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Other (specify)
Are you of Hispanic, Latino, or Spanish origin?
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No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin (specify)
Are you a student?
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Yes, full time
Yes, part time
No
What school do you attend?
How many cigarettes have you smoked in your lifetime?
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< 1 whole cigarette 1-5 cigarettes 6-10 cigarettes > 10 cigarettes
How many times have you used any other forms of tobacco (e.g., hookah, e-cigarettes like JUUL, blunts, cigarillos, etc.) in your lifetime?
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< 1 time 1-5 times 6-10 times >10 times
Have you used any tobacco products, even a puff of a cigarette, in the past year?
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Yes
No
Do you think you might use a cigarette, e-cigarette, or other tobacco product over the next month?
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Definitely Probably Unsure Probably Not Definitely Not
Below is a list of 9 categories of Adverse Childhood Experiences (ACEs). From the list below, please consider each category and whether you experienced this prior to your 18th birthday.
-Did you feel that you didn't have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?
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 -Did you live with anyone who was depressed, mentally ill, or attempted suicide?
 -Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?
 -Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?
 -Did you live with anyone who went to jail or prison?
 -Did a parent or adult in your home ever swear at you, insult you, or put you down?
 -Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?
 -Did you feel that no one in your family loved you or thought you were special?
 -Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?
Please add up the number of options you mentally said, "Yes, I've experienced that," above and select the total number.
0 1 2 3 4 or more
Please add up the number of options you mentally said, "Yes, I've experienced that," above and select the total number.
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0 1 2 3 4 or more
Now I would like to ask you some additional questions about your mental health and medical history. I would like to remind you that answering these questions is voluntary. You are under no obligation to answer them, and not answering them will have no effect on your health care at Duke.
Have you taken any antidepressants, mood stabilizers, ADHD medications, antipsychotics, or opioid pain medications in the past 60 days? (excludes benzodiazepines)
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Yes No
How frequently do you drink alcohol?
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Is the above response greater than once per week?
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Yes No
In the past month, how many times have you had 4 or more drinks within a 2-hour period?
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Have you used marijuana or any other illicit drugs more than 10 times in your lifetime?
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Yes
No
Have you ever sought help for or had any formal treatment for drugs or alcohol?
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Yes
No
Do any of these medical or health issues apply to you?
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Yes, at least one of these applies to me
No, none of these apply to me
Unsure of whether any of these apply to me
Have you ever experienced a head trauma that caused you to lose consciousness?
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Yes
No
Do you have any metal implants or fragments in your body (including but not limited to permanent retainer, pacemaker, braces, plates, screws)?
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Yes
No
Are you claustrophobic (afraid of dark enclosed spaces)?
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Yes
No
Do you have any tattoos or permanent make-up above the neck?
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Yes
No
How tall are you?
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4' 6" or less 4' 7" 4' 8" 4' 9" 4' 10" 4' 11" 5' 0" 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 0" 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" or more
How much do you weigh?
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BMI**note MRI eligibility - BMI < 40, or other evidence (e.g., recent MRI scan) supporting fMRI compatibility
View equation Do you have any routine times during which you will not be able to participate in a study?
How did you hear about this study?
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Craigslist DukeList Flyer Friend/Referral Facebook Other online ad TV ad MyChart Researchmatch.org Other
If you do not qualify for this study, would you like to be contacted for future studies?
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Yes
No
Is the subject web screen eligible?
View equation Complete
Not Complete
Pending
DNQ
Is the subject eligible to enroll?
Yes
No
No, but could be contacted in the future
Has screening visit been scheduled?
Yes
No, screening cannot be scheduled
Pending
Notes about scheduling screening visit
Ineligible Reasons (check all that apply)
Number of Contact Attempts
1
2
3
Notes on Phone Screen Contact Attempts
Reasons Phone Screen Cannot be Completed
Reasons Not Eligible - Calculated
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