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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.

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Required format:

Study Participation Interest Form

Please fill out the following information if you would like your name put on a list for future studies. We may contact you if we begin a study for which you may be eligible. Completing this form does not automatically enroll or obligate you to participate in research. All information entered in the form is confidential and secure.

Thank you for your interest!

First name

Last name

Phone number

Do you give us permission to leave a voicemail if we contact you at this phone number?

Yes

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Alternate phone number (if applicable)

Do you give us permission to leave a voicemail if we contact you at this phone number?

Yes

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Address line 1

Address line 2 (if applicable)

City

State

Zip code

Email address:

Email address (retype):

Please ensure you have entered your email address in both fields correctly.

How do you describe yourself?

Male

Female

Transgender

Do not identify as female, male, or transgender

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What is your birth year?

The next two questions ask if you receive insurance or health care through HealthPartners. Many studies may still allow you to participate even if you are not a patient or a member.

Do you have HealthPartners insurance?

Yes

I used to, but I don't any more

I don't know

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Have you ever received care or services at HealthPartners?

This could include care or services from HealthPartners hospitals, clinics, pharmacies, or dental clinics, as well as Park Nicollet clinics or pharmacies.

Yes

I don't know

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It is important for participants in our projects to represent the communities we serve. The next question will help us understand more about who you are. Please consider responding.

With which racial or ethnic group(s) do you identify? Select all that apply

African Native (including Somali, Amhara, Oromo, etc.)

American Indian or Alaskan Native

Asian (including Hmong, Chinese, Asian Indian, Vietnamese, etc.)

Black/African American

Hispanic/Latino/Latina/Latinx

Middle Eastern/North African

Native Hawaiian or Pacific Islander

White

Another race or ethnicity, please describe:

In which types of studies are you interested in participating? Select all that apply.

Behavioral health (such as depression, anxiety, bipolar disorder)

Cardiology (heart, blood pressure/hypertension)

Community and population research

Critical care/Emergency medicine/Surgery

Dental

Diabetes

General health and well-being

Neuroscience (brain and spine)

Oncology (cancer)

Orthopedics (bones and muscles)

Primary care/Internal medicine

Maternal and child health

Pulmonology (lungs)

Reviewing study materials/General feedback

Other (please specify)

Other, please specify:

Do you have diabetes?

Yes

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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.