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Record ID
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Is consent required for this study?
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Date of Consent
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I agree to let The Duke Clinical Research Institute to collect all identifiable information.
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I agree to let The Duke Clinical Research Institute to collect my Social Security number.
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I agree to let The Duke Clinical Research Institute to collect only my zip code and no other identifiable information.
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I agree to be contacted for future research.
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County
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Zip Code
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Date of Sociodemographic Data Collection
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What is your race?
Mark one or more boxes AND print origins.
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race_ethn_asian_detail
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race_ethn_islander_detail
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Specify other origin.
Print race of origin.
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Are you of Hispanic, Latino, or Spanish origin?
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Please specify your origin
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Please specify other Hispanic, Latino, or Spanish origin. For example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc.
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Age
For babies less than 1 year old, do not write the age in months. Write 0 as the age.
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What was your sex assigned at birth?
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What terms best express how you describe your gender identity?