Form 1 Web-based Screener

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information
collection is estimated to average 4 minutes per response, including the time to review instructions, search existing data sources, gather the data
needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA(XXXX-XXXX). Do not return the completed form to this address.
OMB Number: XXXX-XXX
OMB Expiration Date: XX/XX/XXX

Attachment 2 – Web-based Screener
OMB Number: TBD

1

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 2

http://impact.02.sgizmo.com/s3/

1/14/2013 12:16 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

2 of 2

http://impact.02.sgizmo.com/s3/

1/14/2013 12:16 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 12:17 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 12:18 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 12:22 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 2

http://impact.02.sgizmo.com/s3

Click here to save your progress

1/14/2013 1:27 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 1:27 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 1:28 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 1:28 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 1:28 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 1:28 PM

Blood DROPS MSM and Donor Survey Draft January 10, 2013

1 of 1

http://impact.02.sgizmo.com/s3

Click here to save your progress
and return later to complete survey.

1/14/2013 1:29 PM