Peanut Immune Study Screening Form | School of Public Health

First Name

Last Name

Cell Phone Number

Preferred Method of Contact

Date of Birth

Height

Weight

City/Town

State/Province

The following information is needed to properly assess your qualification to participate in the Peanut Immune Study conducted by Loma Linda University and will be used per Study Protocol guidelines.

Have you had any vaccination this year?

If yes, please provide the date of vaccination

Do you have any auto-immune disease like lupus, rheumatoid arthritis, hashimoto disease etc.

Are you allergic to peanuts?

If you are not allergic to peanuts, how often do you eat them?

Upon reviewing the information you provided, we will inform you of your eligibility to attend our study information session which is the next step in the process to identify eligible participants. In order to reach you with this information, please indicate the best times to reach you:

Morning 8:00 am – 12:00 pm

Afternoon 12:00 pm – 5:00 pm

Evening 5:00 pm – 8:00 pm

How did you learn about the study?