Eligibility Form

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:

k4tJ7BozBgNcUiw77NmIzdhk67Vcy9V7nqWrTAuowGn5GtRcVXP

Thank you for your interest in this Miriam Hospital study: MyReport (My Real Experiences and Personal Observations Recorded Today).

This research study will investigate the use of e-cigs/vapes, regular cigarettes, alcohol, AND/OR marijuana, and stress in daily life among young adults (ages 18-25). Eligible participants will visit the lab once to complete questionnaires and computer tasks, fill out daily surveys for 35-days on your personal smartphone and provide saliva samples collected at home. Participants will be paid for their time.

If you are interested in participating, please complete the following questions. If you are eligible to participate, a member of our research staff will contact you.

Note: This is not a mental health treatment study. You will not receive substance use or mental health treatment. This is a National Institute of Health sponsored non-clinical trial research study.

By clicking "Submit" at the end of this survey, you are agreeing to share your survey responses with a study representative. This information is kept completely confidential and will be used for screening purposes.

What is your age?

* must provide value

What was your biological sex assigned at birth?

* must provide value

Female

Male

Intersex

reset

What state do you live in?

* must provide value

Rhode Island

Massachusetts

Connecticut

Neither of these

reset

Are you currently on any of the following birth control methods?

* must provide value

Oral (the pill) or Birth Control Pill (combined pill or progestin-only pill)

Hormonal IUD (e.g. Mirena, Kyleena, Skyla)

Shot or Injection (e.g. Depo-Provera or Noristerat)

Vaginal ring or Vaginal contraceptive ring (e.g. NuvaRing)

Not on hormonal birth control

Copper IUD (e.g. Paragard)

Contraceptive patch (e.g. Ortho Evra)

Implant (e.g. Nexplanon)

Other

Other:

* must provide value

Have you used any electronic nicotine delivery systems (includes: e-cigarettes, vape pens, personal vaporizers, mods, e-cigars, e-pipes, e-hookahs, JUUL, and hookah pens; must contain nicotine) in the PAST MONTH?

* must provide value

Not at all

Some days

Everyday

reset

Have you smoked regular cigarettes at least once in the PAST MONTH?

* must provide value

Yes

reset

Have you used alcohol at least once in the PAST MONTH?

* must provide value

Yes

reset

Have you used marijuana at least once in the PAST MONTH?

* must provide value

Yes

reset

Are you currently a college or university student?

* must provide value

Yes

reset

Are you Hispanic, Latino/a or Latinx?

* must provide value

Yes

reset

What is your race?
(Select all that apply.)

* must provide value

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Other

Please specify Other:

* must provide value

How did you learn about our study?

* must provide value

Facebook

Instagram

Snapchat

Twitter

TikTok

Flyer

School email

Craigslist

Other

reset

Please specify Other:

* must provide value

Name:

* must provide value

Primary phone number:

* must provide value

Best time to call:

* must provide value

E-mail address:

* must provide value

Can we email you?

* must provide value

Yes

reset

Please select a contact method:
(Select all that apply.)

Note: Contact method needed to conduct COVID-19 screening for in-person session.

* must provide value

Text

Call

Both

Please find the attached Lifespan Privacy Notice for your reference.

Attachment:Lifespan Privacy Notice + Amendment.pdf

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.