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Field study clinical trial site eligibility screener

Thank you for your interest in participating in the Materials to Increase Minority Involvement (MIMICT) field study. Please note that your participation in this field study is voluntary.

If you have any questions about the field study, please call, text, or email Kelsi Jackson, a research assistant at KDH Research & Communication (KDHRC), at 404-968-8013 or

Please follow these instructions to complete the form:
  • Complete the form all at once.
  • Keep the browser window open the whole time.
  • Do not use the back button or your answers will be lost.
  • If the form stops working or you have technical problems, start the form again.
To begin, we need you to provide a few pieces of information.