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Pre-Screening Questions

Your information will not be sold or shared with third parties for their own separate use.

1. What is the potential participant’s month and year of birth? (Parents or legal guardians of potential participants under 18 may answer, and complete the questionnaire on behalf of the child).
Month Year
   
2. Please select the age range that the potential participant currently falls under:



3. Is the potential participant currently pregnant or nursing?



4. Do you think the potential participant could have pink eye? Signs/symptoms could include:
  • Eye redness
  • Eye watering/discharge
  • Eye(s) feeling sore
  • Sometimes a white or yellow discharge from the eye that may stick to the eyelashes

5. Do you/they have any of the following ophthalmic conditions: Retinopathy of Prematurity, cataracts, and/or glaucoma?