Asia Microbiota Bank Donor Health Survey (V.2)

General Information - Page 1 of 3

Thank you for agreeing to take the following Asia Microbiota Bank Volunteer and Donor Health Survey.

We are looking for volunteers and donors who:

1. Are able to make regular visits (at least 3 times a week for 3 consecutive months) to our laboratory in Central area for stool collection.

2. Are exceptionally healthy.

Since people with severe illness may receive the stool bacteria you donate, we request your complete honesty in answering these questions. By filling out this survey, you consent to the Asia Microbiota Bank using this personal and health information for the purpose of evaluating your eligibility to become a qualified stool donor or scientific research volunteer. Any data collected will be kept confidential and used only for the purpose of the donors recruitment project.

PLEASE COMPLETE ALL THREE PAGES OF THE HEALTH SURVEY, OTHERWISE YOUR APPLICATION WILL NOT BE CONSIDERED.

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* 1. Please enter your contact information (even if you have supplied it previously, thank you!)

First Name

Last Name

Phone Number

Email Address

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* 2. What is the nearest MTR Station to your house?

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* 3. What is the nearest MTR Station to your work location?

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* 4. Are you male or female?

Male

Female

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* 5. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 6. Please describe your race/ethnicity.

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* 7. What is your current height in centimeters?

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* 8. What is your approximate weight in kilograms?

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* 9. In general, how would you rate your overall health?

Excellent

Very good

Good

Fair

Poor

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* 10. What is your current work profession?

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* 11. Do you currently live or work in Central area?

Yes

Great! Thank you for completing the first page! Next you will answer some detailed questions about your health. Please click next.

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* 12. If you qualify for the donor recruiting program, how many times per week could you commit to dropping off your stool donation?

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 13. Can you commute to the Central area within 30 minutes between the hours of 08:00 and 18:00 Monday - Friday at least 3 times per week?

Yes