The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Screening Questionnaire

Hello!

Thank you for your interest in participating in the HYPHY study. To see if you qualify to participate, please complete the screening survey below.

Thank you!

ADORLab

Study ID

* must provide value

Date of survey completion

* must provide value

M-D-Y

Last name

* must provide value

First name

* must provide value

Middle name

Phone number

* must provide value

Email address

* must provide value

What is your zip code?

* must provide value

How long have you lived within this zip code?

* must provide value

less than 6 months

6 months or more

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What zip code did you live in before your current one?

* must provide value

Have you traveled out of your zip code in the past SIX months?

* must provide value

Yes

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For how long were you traveling?

* must provide value

two weeks or less

more than two weeks

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When did you return from traveling?

* must provide value

< 30 days ago

at least 30 days ago or longer

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Date of birth
(Note you will be asked to confirm date of birth during onboarding phone call)

* must provide value

M-D-Y

Age (calculated)

View equation

Biological sex

* must provide value

Female

Male

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Height (feet)

* must provide value

Height (inches)

* must provide value

Height (inches calculated)

View equation

Weight (pounds)

* must provide value

BMI (calculated)

View equation

Primary language spoken

* must provide value

Other (language)

What is your racial background? (Select all that apply)

* must provide value

White

Black (African-American)

Asian

Native Hawaiian or Pacific Islander

American Indian (Native American) or Alaska Native

Other

(Other) race

* must provide value

Are you of Hispanic or Spanish or Latino descent?

* must provide value

Yes

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Mexican

Central American

South American

Other

Mother

Father

Paternal grandmother

Paternal grandfather

Maternal grandmother

Maternal grandfather

You

Other (mother's ethnicity)

Other (father's ethnicity)

Other (paternal grandmother's ethnicity)

Other (paternal grandfather's ethnicity)

Other (maternal grandmother's ethnicity)

Other (maternal grandfather's ethnicity)

You (your ethnicity)

Where was your mother born? Please fill in the state or country. If unsure, type Unknown.

* must provide value

Where was your father born? Please fill in the state or country. If unsure, type Unknown.

* must provide value

Where was your paternal grandmother born? Please fill in the state or country. If unsure, type Unknown.

* must provide value

Where was your paternal grandfather born? Please fill in the state or country. If unsure, type Unknown.

* must provide value

Where was your maternal grandmother born? Please fill in the state or country. If unsure, type Unknown.

* must provide value

Where was your maternal grandfather born? Please fill in the state or country. If unsure, type Unknown.

* must provide value

Where were you born? Please fill in the state or country. If unsure, type Unknown.

* must provide value

Have you taken any antibiotics in the past month?

* must provide value

Yes

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Are you pregnant or currently nursing?

* must provide value

Yes

N/A

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Do you have any of the following medical conditions? (Select as many as apply)

* must provide value

Type 1 diabetes

Type 2 diabetes

Intestinal bowel disease

Crohn's disease

Kidney disease

Heart disease

Autoimmune disease

None of these

Have you had bariatric surgery (surgery to reduce the size of the stomach by (1) use of a gastric band or (2) by removing of a portion of the stomach or (3) by resecting and re-routing the small intestine to a small stomach pouch)?

* must provide value

Yes

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Are you currently employed?

* must provide value

Yes

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Does your schedule include any night shifts?

* must provide value

Yes

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How many night shifts (at least 3 hours of work between midnight and 6am) do you on average work per month?

* must provide value

None

1-3

4-6

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What other shifts do you work in addition to night shifts? Select as many as apply.

* must provide value

Early morning shifts

Day shifts

Afternoon shifts

Evening shifts

On-call

None

For how many years have you worked this schedule?

* must provide value

less than 2

2-5

5-10

more than 10

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How did you hear about our study?

Craigslist ad (under "community -> volunteers")

Craigslist ad (under "gigs")

Craigslist ad (under "jobs -> etc/misc")

Facebook ad

Twitter

Flyer (in my community)

Mailer

Flyer (LIVE Denver)

Flyer (Denver Housing Authority)

Flyer (Habitat for Humanity of Metro Denver)

CU Integrative Physiology (IPHY) website

Referral

We would like to keep your contact information on file so we can notify you if we have future research studies we think you may be interested in. This information will be used by only the principal investigator of this study and only for this purpose. The database will only be accessible to Dr. Alderete, and dedicated investigative research personnel. Access will be password-protected. No link to study data will be available, as the only available hardcopy of the key to do so will be stored separately in a locked room, in a locked file cabinet, only available to Dr. Alderete.

* must provide value

Yes, you may contact me for future research studies.

No, you may not contact me for future research studies.

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Do you prefer to be re-contacted using the email or phone number specified above?

* must provide value

Phone

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Zip code eligibility

View equation

Is the participant eligible? 1= Yes, 0 = No
Also check for duration at zip code (not a disqualifier, but maybe recontact if they are near 6 mos at zip code to participate later)
NOT IN EQUATION BUT LOOK AT TRAVEL AND SCHEDULE 30 DAYS AFTER RETURN IF ELIGIBLE, TRAVEL MUST BE 2 WEEKS OR LESS IN DURATION

View equation

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.