Columbia USA Online Volunteer Registration Form
Boxes/questions marked with * must be filled in.
Full Name
*
First Name
Last Name
Gender
Male
Female
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Email Address
Valid Home Phone
*
-
Area Code
Phone Number
Other/alternate phone # (optional)
-
Area Code
Phone Number
What is the best time to contact you
*
Mornings
Afternoons
Evenings
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Current approximate height (inches)
*
Current approximate weight
*
Ethnicity
*
(Hispanic/Latino, Asian, Black, White, Mixed Race)
Do you smoke or use tobacco products (including occasional smoking)?
*
Yes
No
If yes, how many times a day/week /month do you smoke or use tobacco products (e.g. cigarettes, cigars, pipes or dips)?
If no, have you ever smoked or used tobacco products in the past?
*
Yes
No
If yes, when did you start and date you quit
Do you have a history of alcohol abuse or dependence (e.g. alcoholism)?
*
Yes
No
If yes, please specify date of last treatment
Do you consume any alcohol containing products?
*
Yes
No
If yes, what type and how many drinks a day/week /month
Do you have a history of drug abuse or dependence?
*
Yes
No
Do you use or have you used illicit or street drugs and/or any other drug of abuse (e.g. marijuana, cocaine, hash)?
*
Yes
No
If yes, please provide the name of the illicit drug(s) and date of last use
Are you taking any over the counter medication (e.g. Aspirin, vitamins, herbal/natural supplements, Tylenol)?
*
Yes
No
If yes, please provide the name of the medication and date of last use
Are you taking any prescription medication (e.g. blood pressure medications, cholesterol medications, antibiotics, sleeping pills, antidepressants)?
*
Yes
No
If yes, please provide the name of the medication and date of last use
Have you donated blood in the last 56 days?
*
Yes
No
If yes, please specify the date and the amount of blood
Are you participating / have you participated in any other clinical trials elsewhere?
*
Yes
No
If yes, when was the last study completed?
How often do you participate in clinical trials/studies (per year)?
Have you been ill in the last 30 days?
*
Yes
No
Do you have difficulty swallowing pills, capsules or liquid medications?
*
Yes
No
Are there any foods you will not eat due to personal and/or religious reasons?
*
Yes
No
If yes, please specify
Have you ever had any surgeries of any kind (e.g. heart, kidney, liver, bowel, bone fracture repair surgery)
*
Yes
No
If yes, please specify the type and date of the surgery
Do you have any allergies (e.g. food, drugs, environmental)?
*
Yes
No
If yes, please specify including the type of the reaction
Any presence or history of endocrine problems (e.g. diabetes)?
*
Yes
No
If yes, please specify
Any presence or history of heart problems (e.g. low or high blood pressure, angina)?
*
Yes
No
If yes, please specify
Any presence or history of respiratory problem (e.g. asthma, bronchitis, pneumonia, tuberculosis)?
*
Yes
No
If yes, please specify
Any presence or history of liver problems (e.g. hepatitis B ,C, liver cirrhosis )
*
Yes
No
Any presence or history of muscle and/or bone problems (e.g. rheumatoid arthritis)?
*
Yes
No
If yes, please specify
Any presence or history of kidney and/or bladder problems (e.g. kidney stones, urinary tract infection)?
*
Yes
No
If yes, please specify
Any presence or history of gastrointestinal problems (e.g. ulcer, gastritis, colitis, chronic diarrhea/constipation, hemorrhoids)?
*
Yes
No
If yes, please specify
Any presence or history of psychiatric and/or psychological disorders (e.g. depression, anxiety)?
*
Yes
No
If yes, please specify
Any presence or history of neurological disorders (e.g. migraines, seizures including epilepsy)?
*
Yes
No
If yes, please specify
Any presence or history of skin problems (e.g. eczema, psoriasis)?
*
Yes
No
If yes, please specify
Any presence or history of immunological problems (e.g. systemic lupus erythematosus)?
*
Yes
No
If yes, please specify
Any presence or history of hematological (blood) disorders (e.g. anemia)?
*
Yes
No
If yes, please specify
Do you have any other medical conditions and/or health problems?
*
Yes
No
If yes, please specify
Do you agree for us to contact you for future study participation?
*
Yes
No
For Females Only
Do you agree for us to contact you for future study participation?
Able to have children
Post-menopausal
Surgically Sterile
If able to have children, is your menstrual cycle regular?
Yes
No
If yes, please specify cycle days (e.g. 21, 28, 30)
Submit Form
Clear Form
Should be Empty: