This form will take approximately 15 minutes. You will go through a list of questions. You may choose not to answer these questions. You also may choose to stop participating in this interview at any time; if you want to stop, you can leave this page at any time.

Information about you that you give me during this interview will be kept as confidential as possible as required by law. It is possible that the Food and Drug Administration, and other federal and state authorities, may inspect this record.

You can choose if you want or do not want to take part in this research screening procedure – it is up to you. If you refuse to answer the questions or stop answering them at any time, there will be no penalty, and you will not lose any benefits to which you otherwise would be entitled.

The screening interview is not designed to ask you for sensitive personal information, but it is possible that some people may feel uncomfortable answering these questions with a person they do not know; however, this information allows us to assess if you are eligible for our study. If you qualify to take part in the study and are interested in taking part in it or in future research studies, then please proceed and submit your name and information; this will be kept confidential, but there is a small risk that people outside of the research team/University/Hospital could learn this information. If you are not interested in the study, please leave this page.

If you have any questions, concerns, or complaints about this form, please contact Jiwon Yeon at jyeon@stanford.edu. If you want to talk to someone separate from the research team about a concern or complaint or your rights as a possible research subject, please contact the Stanford Institutional Review Board (IRB) to speak to an informed person who is separate from the research team, at 650-723-5244 (for medical studies), 650-723-2480 (for nonmedical studies), or toll-free at 1-866-680-2906.