Submit an Application Today. To be eligible to participate in a clinical research study, simply submit an application. "*" indicates required fields Have you previously submitted an application?*---NoYesAre you trying to update your information?*NoYesPlease contact the QPS Recruiting Office at 417.831.2048 NameFull Legal Name (As it appears on your Social Security Card)* First Middle Last Date of BirthDate of Birth* MM slash DD slash YYYY GenderSex Assigned at Birth* Male Female RaceRace*WhiteBlackAmer. IndianAsianAlaskaHawaiianPacific IslanderHeight & WeightHeight (Feet)*Height (Inches)*Weight (lbs.)*Body Mass Index (BMI)BMI %*AddressAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone NumbersPrimary Phone #*Alternate Daytime #*By providing your mobile phone number, you are giving consent to send you text messages and/or automated calls regarding clinical research trials. Your cellular provider's message and data rates may apply. Please notify us immediately if you change mobile numbers or plan to provide your phone to another person.Are you able to read, write and comprehend without the help of others?* Yes No Email AddressEmail* Enter Email Confirm Email *By providing your email address, you expressly consent to receive emails from us.Women OnlyMethod of Birth Control*AbstinenceAlternate LifestyleCondom/SpermicideDepo ProveraEssureTubal LigationHysterectomyImplantIUD/IUSOophorectomySalpingectomyNaturally PostmenopausalNuvaRingPatchOral PillVasectomized PartnerNoneTobaccoDo you currently smoke cigarettes?* Yes No Do you currently use chewing tobacco?* Yes No Do you currently use an electronic nicotine delivery system?* Yes No General QuestionsHave you ever been diagnosed with Hepatitis C, B or HIV?* Yes No Do you currently take any prescription medications for a chronic condition?* Yes No Do you have any known drug allergies* Yes No How did you hear about QPS?* Billboard Email Google Print Radio Television Referral If referred by a friend or family member, please include their name.This field is hidden when viewing the formWhich clinical research study are wanting to participate in? 50523 - Rheumatoid Arthritis, ages 18 - 70 years 51823 - Smokers, ages 22-65 years 57123 - Healthy adults, 50 years of age and older I am interest in participating in ANY clinical research study. Which clinical research study are wanting to participate in?*Select a study...250011 - Healthy, ages 18 to 50250022 - Smoker, ages 22 to 64250023 - Healthy, Lactating Women, ages 18 years of age and older250025 - Type II Diabetic, ages 24 - 756292428211 - Autoimmune/Disease State Required, ages 18+6512448211 - Autoimmune/Disease State Required, ages 18+I am interest in participating in ANY clinical research study. I confirm that the information provided on this application is, to the best of my knowledge, complete and accurate. I confirm that I have read and expressly consent to provide my personal information to QPS Missouri in accordance with these terms and conditions. I understand that this information will be used for the sole purpose of determining my eligibility to volunteer for a clinical research trial. I understand that QPS Missouri will use its best efforts to treat my information provided in this registration form with security and confidentiality. I understand that this information may be seen by QPS Missouri Sponsors, their affiliates, vendors and representatives, and government or regulatory authorities. The contact information I provide may be retained in a database owned by QPS Missouri. I consent to be contacted by QPS Missouri and its service providers via email, phone or text message and that standard usage rates may apply. I confirm that I am 18 years or over. Participant Signature*Date* MM slash DD slash YYYY CAPTCHA Δ
