Date of Birth
What is the primary phone number (include area code) to use for contact and leaving messages?
Can we contact you via text message?
Please be aware: The PreciousEggs Program requires participants to visit our Delaware office many times during the donation process.
Do you have a social security number?
Are you eligible to work in the United States?
What is your current occupation?
Is your work schedule flexible?
Please explain your schedule limitations
Are you a US citizen or permanent resident?
Do you have a drivers license or state issued ID?
Do you have reliable transportation for appointments at our offices in Delaware?
What type of transportation will you be using to attend appointments (i.e. I own a car, renting a car, train, bus)?
Were you adopted by a family member?
What is your height?
What is your weight?
What type of contraception are you currently using?
IUD (explain type)
Birth Control Pills
Other (explain type)
When was your last injection, and are you willing to discontinue use? *
Are you willing to have the Implanon removed, and if so, when? *
When was your last period? *
Please explain *
Have you smoked in the last 2 months?*
Which ethnicity would you most likely be affiliated with?
Indian (from India)
Have you applied or been screened to be an egg donor before?
Yes, was accepted but never donated
Yes, was accepted and donated
Yes, was not accepted
Yes, applied but was never accepted or declined
How many times have you donated?
Are you currently enrolled as an egg donor in another program?
Yes, and I AM NOT under a contract which prevents me from applying to other agencies
Yes, and I AM under a contract which prevents me from applying to other agencies but I want out of that contract
Yes, and I AM under a contract which prevents me from applying to other agencies but I am applying anyway
Which best describes your level of education?
Did not complete high school
Completed high school
Technical school degree
Currently enrolled in college
Completed college 2 year degree
Completed college 4 year degree
Currently pursuing an advanced degree
Completed advanced degree
If you are currently in college, what year?
Not in college
Which field did you study/graduate from?
Did you have any learning disabilities or weaknesses in school?
Please explain your learning disabilities/weaknesses
Please provide your scores (Grade Point Average (GPA) as current as competed) for the following (Leave blank if you do not know / remember your score). *
Have you had a medical diagnosis of Zika virus infection in the past 6 months?
Have you resided in, or traveled to, an area with active Zika virus transmission within the past 6 months?
Have you had sex within the past 6 months with a male who is known to have either of the risk factors listed in the above 2 questions?
Do you plan on traveling in the next 6 months (please think about any Spring Break or summer plans when answering this question)?
When, and where?
Have you traveled outside of the continental U.S. in the last 6 months?
When, and where?
Have you had fever, rash, joint pain, or red eyes since your travel to this area?
In the past 12 months, have you been in close contact with a person having active viral hepatitis?
In the past 12 months, have you had sex with a man who has had sex with another man in the past 5 years?
In the past 12 months, have you had a positive syphilus test?
In the past 12 months, have you been treated for gonorrhea or chlamydia?
What were you treated for, and when?
Have you spent 3 months or more cumulative in the United Kingdom from 1980 through 1996?
From 1980 through 1990, were you a member of the US military, a civilian military employee or a dependent member of the US military, residing in US military bases in Northern Europe (Germany, Belgium, and the Netherlands) for 6 months or more, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, Italy) for 6 months or more from 1980 through 1996?
Have you spent 5 or more years cumulative in Europe?
In the past 12 months, have you been in jail for more than 3 days in a row?
How did you hear about us?
Referred by a friend
Reproductive Associates of DE website
Campus Flyer - Specify which school
Donor - Please specify
Employee - Please specify
Other - Please specify