Thank you for your interest in becoming a stool donor!

Please answer all questions of this survey completely to be considered for the next phase of the application process. Being completely honest in your answer, to the best of your ability, is very important to patient safety.

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1. Please enter your contact information below:

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2. What is your date of birth? MM/DD/YYYY

Date

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3. What is your gender?

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4. What is your current height (in feet and inches)?

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5. What is your current weight in pounds (lbs)?

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6. Will you be living or working in the greater Boston area for the next six months?

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7. What is the ZIP code of your

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9. Have you applied to be a donor for OpenBiome before?

By participating in this survey, you are agreeing to allow the OpenBiome clinical team to use the information you provide to help determine your eligibility as a stool donor. No one outside the clinical team will be able to connect your responses with any information that identifies you, such as your name, date of birth, email address, and other contact information. If you do not qualify for the stool donation program or choose not to participate, we will not keep any of your identifying information.
 
33% of survey complete.

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