Screening Form
for Possible Participation in a Research Study

The following questions will help us determine
your suitability for participation in this study.


PLEASE NOTE: This is NOT the form to volunteer for a specific study seeking healthy volunteers.  Access to the specific study form is through one of the "View" options.  Click here to return to the Trial Listings.  

This form is to be used if you would like to be added to the general GCRC database of healthy volunteers for possible participation in any research study, now or in the future.  When completed you may be called by one or more of our Study Coordinators.  Filling out this form in no way obligates you to participate in a GCRC research study.  

Fields in red are required.

Today's Date: (Use Format: mm/dd/yyyy)

First Name:        Last Name: 
Street Address 1: 
Street Address 2: 
City:       State:        Zip Code: 


Daytime telephone:     Evening telephone:
E-mail address (if you have one): 

Height (feet/inches):           Weight (lbs):  

Date of Birth: (Use format: MM/DD/YYYY)          

Gender:  Male    Female
Do you work the night shift?   Yes    No
Have you been in a previous study at the University of Virginia?   Yes     No
Would you object to staying overnight at the hospital?   Yes    No

Would you mind being called by other investigators
regarding participation in other studies?     OK to call     Do not call

Type in any additional comments or information.
1. INFORMATION USAGE AND CONFIDENTIALITY
a) The University of Virginia General Clinical Research Center (GCRC) agrees to undertake all reasonable efforts to safeguard the information you are providing on this web site so as to prevent unauthorized disclosure.
b) Subject to section 1a you understand and agree that the GCRC may use the information entered by you into this web site for the purpose of recruitment for clinical research or clinical trials being run on the University of Virginia GCRC.  

2. LIMITATION OF LIABILITY
The University of Virginia GCRC will not be held liable for inadvertent disclosure of the data you provide on this web site that may result in direct or indirect damages arising from such inadvertent disclosure.

3. CORRECTIONS OR TERMINATION OF DATA
Your listing as a potential research subject will continue until terminated.  You may terminate your listing or correct any collected data at any time by sending electronic mail to gcrc@virginia.edu indicating that you wish to have your information removed from the database or corrected, in which case the GCRC agrees to correct or permanently remove the information from the database within 30 days of receiving such electronic mail.  You must supply your full name, address, phone number and date of birth in order to correct data or be removed from the database by the UVa GCRC.

Should you have any questions concerning this web site, or if you desire to contact the University of Virginia General Clinical Research Center for any reason, please write to: 

General Clinical Research Center
University of Virginia Health System
PO Box 800787
Charlottesville, VA 22908-0787
Attn: Administrative Manager