RM_Stats(1 of 4)PARTICIPANT INFO* First name* Last name* Email* State or Province (abbrev. preferred)XX* Zip codeCountry (if from Canada)* Date survey completedplease add date of survey (mm/dd/yyyy)(2 of 4)BASIC PERSONAL INFORMATION* Age (in years)* GenderSelect an optionMaleFemaleOther* Approx. weight in lbs.* Approx. height in inches* Education levelSelect an optionless than 12 grades completedhigh school diploma2-year college degree4-year college degreeadvanced degree(3 of 4)LIFESTYLE QUESTIONSWITHIN THE LAST 30 DAYS...* Occupation* Do you live or work near a farm?Select an optionwithin 100 feetwithin 500 feetwithin ¼ milewithin 1/2 milemore than 1/2 milenot near a farm* Have you visited a non-organic farm in the last 30 days?Select an optionYesNo* How would you characterize the area where you live?Select an optionurbansuburbanrural* Do you work outdoors?Select an optioneverydaya few times per weekonce per weekrarely or never* Do you play golf?Select an optionneveroccasionallyonce per weekmore than once per week* Do you visit local or state parks?Select an optionneveroccasionallyonce per weekmore than once per week* Do you use Roundup or other herbicides (weed killers) at home or work?Select an optionfrequentlyoccasionallynever* Do you have a lawn care service spray your lawn?Select an optionfrequentlyoccasionallynever(4 of 4)DIETARY QUESTIONSWITHIN THE LAST 30 DAYS...* How many servings of fruit and vegetables do you eat per day? (assume 3-4 ounces per serving)assume 3-4 ounces per serving* Do you consume fresh juices or smoothies?Select an optionevery day4-5 days per week2-3 days per week1 day per weekrarely or never* Do you consume beer or wine?Select an optionevery day4-5 days per week2-3 days per week1 day per weekrarely or never* Do you consume non-organic oats (i.e. as oatmeal, in cookies, muffins, or as oat flour)?Select an optionevery day4-5 days per week2-3 days per week1 day per weekrarely or never* Do you consume non-organic whole wheat products (i.e. bread, crackers, shredded wheat, wheat bran, or whole wheat flour)?Select an optionevery day4-5 days per week2-3 days per week1 day per weekrarely or never* How often do you consume non-organic soy (i.e. soy sauce, edamame, meat substitutes like tempeh or tofu)?Select an optionevery day4-5 days per week2-3 days per week1 day per weekrarely or never* How often do you consume other non-organic legumes (i.e. beans, peas, lentils, chick peas, hummus)?Select an optionevery day4-5 days per week2-3 days per week1 day per weekrarely or never* What percentage of your diet would you estimate is organic?Select an option0-10%10-30%30-50%50-75%75-100%* How many meals do you eat outside of home per week?Select an option0-34-78-1415-21* What type of diet do you maintain?:Select an optionomnivorevegetarianveganpescatarian (fish+vegetarian)* Is most of the water you consume:Select an optioncity/municipal waterwell waterspring waterfiltereddistilledbottledrainwaternot sureIf you are the parent or guardian of a study participant who is under 18 years of age and whose data you are providing in this survey, please enter your name, here:* Terms, Conditions and Consent FormTerms, Conditions and Consent FormStandard Terms and Conditions: By checking “I agree” in the study survey, I indicate that I have read the statement below and choose to enroll in this project, or I am the parent or guardian enrolling a participant who is under the age of 18. This authorization is equivalent to my signature. Authorizations: I request, authorize and consent to laboratory testing. I understand that test results are strictly informational. Results should not to be used for diagnosis, monitoring, prevention or treatment of disease or impairment of, or the assessment of health. I understand that I should consult with my physician if I have specific questions about my health. I authorize Health Research Institute (HRI) to contact me with study results and study updates. Confidentiality: HRI regards confidentiality as the cornerstone of professional protocol. It is HRI's strict policy to release test results only to the contact person specified by the study participant for that test, and to no one else, unless we have received specific written instructions to do so. This Policy on Confidentiality applies both to test findings and to the names and personal information of all study participants. Remedies: In the event of a material error by Health Research Institute (HRI) in the performance of analysis HRI’s sole obligation shall be for HRI to either (a) repeat the analysis at HRI's own cost, or (b) refund or credit the invoiced amount. In no event shall HRI Labs' liability in connection with any sale hereunder exceed the price paid for the service in issue. Indemnification: I indemnify HRI and its directors, officers, employees, and agents from any loss, cost, damage or expense (including reasonable attorneys' fees) from any lawsuit, action, claim, demand or proceeding arising from or associated with, directly or indirectly, HRI’s execution and/or performance of its services. Consent Form: Purpose: A great deal has been learned about the impacts of glyphosate and other pesticides (insecticides, herbicides, fungicides, and other agrochemicals) and household and industrial chemicals on health and the environment. Yet, a great deal more needs to be understood. One of the big questions is what are the routes through which people become exposed to these chemicals. Exposure could be happening through many channels, including, the food we eat, the water we drink, the air we breathe, and direct contact in the places where we live, work and play. This research investigates human exposure to agrochemical and environmental contaminants through analysis of urine samples. Your participation in this study—both by submitting a urine sample (or multiple samples, in some cases) and by filling out the short online survey—will contribute in a very important way to the depth of data that we can gather. Our goal is to test at least 10,000 subjects and to test these subjects for a number of different agricultural, household and industrial chemicals over time. A subject population of this scope will assure that the results are highly accurate and meaningful. Procedure: Individual participants, or their medical practitioners, obtain urine samples and mail them to Health Research Institute for analysis. Individual participants also complete a survey online with questions related to possible pathways of exposure to agrochemicals and environmental contaminants. Investigators include urine samples and surveys in the research project and save these for future research. Each subject’s sample and survey will be labeled with the same arbitrary number and stored without any personal identifying information. Because each sample and survey will not be linked to the participant’s name after it is stored, consent to use these cannot be withdrawn after the sample is received. Health Research Institute will remove identifying information (such as name, email, street address, and payment information provided when sample collection kits are ordered, samples are submitted, or study surveys are completed,) that can identify you prior to using the data for research. Risks: Sample collection is non-invasive, so no physical health risk is associated with participation. A small number of subjects may have very high levels of agrochemicals or environmental contaminants, which may be emotionally upsetting to them. Benefits: Participants learn about the levels of specific chemicals in their own physiology. They have the opportunity to learn about the results of the broader research study and to understand their personal levels of chemicals relative to those of the study participants as a whole. They also contribute personally and directly to research that has the potential for improving health and the environment. Costs: Your decision to participate in the study is voluntary. There is a cost associated with participation. In general, each participant pays for the analysis of his or her own sample. Confidentiality: This study is for research purposes and all records relating to individual subjects will be kept confidential and will be disassociated from the subject’s sample and survey. Without your express permission, no information will be released or printed that would disclose your personal identity. Informed Consent: I certify that the research procedures described on this form have been explained to me and that any questions that I have asked have been answered to my satisfaction. I understand the benefits and possible risks (if any) of participating in this research. I know that I may ask now, or in the future, any questions I have about the study or the research procedures. I have been assured that records relating to me will be kept confidential. I hereby consent to participate in this study.Do you have any feedback on this survey?