The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

pHjBDhYvwSLKthrID4EsBMj6V9YyWQwfV3vzKiPQajG9PpzSifmP3QfsvALpgm

HARP Initial Maternal Screening Form

Thank you for your interest in participating in the Hemophilia A Research Program (HARP) study. The HARP study seeks to learn about how hemophilia A affects mothers and babies. To see if you are eligible for the study, we need to ask you a few personal health questions. You don't have to answer any question you don't want to answer. If you do not want to answer, select 'Prefer not to answer.'

Please answer these questions to see if you may be eligible.

Are you currently pregnant?

Yes

Prefer not to answer

reset

We are sorry, this questionnaire is for pregnant people only. If you become pregnant in the future, please come back.

Are you currently age 18 or older?

Yes

Prefer not to answer

reset

We are sorry, only people over the age of 18 are allowed to participate in our study. When you are 18 years old or older, please come back.

Is it possible that you have or carry a DNA change (previously called a "mutation") that causes hemophilia A? Sometimes females with these gene changes have been called carriers.

Yes

Not sure

Prefer not to answer

reset

We are sorry only pregnant people who might have a DNA change that causes hemophilia A are allowed to participate in our study. If you learn that you might have a DNA change like this, please come back.

Is it possible that your future child could be at risk to have hemophilia A?

Yes

Not sure

Prefer not to answer

reset

We are sorry, you are not eligible for our study unless there is a chance your future child might have hemophilia A.

Thank you for your interest in the HARP study. At this time, you do not appear to be eligible to participate.

If you think this may be a mistake, please contact the HARP at: harp@rti.org
If your answers change in the future, please consider coming back to see if you could be eligible to participate.
Are you interested to hear what is happening in the HARP? You can sign up to receive updates at: https://harpf8.org

Thank you for your interest in the HARP study. It looks like you may be eligible to participate. Please fill out the information below and we will contact you soon.

Thank you for your interest in the HARP study. At this time, we are unsure if you are eligible to participate. If you would like a HARP study staff member to reach out to you, please fill out the information below and we will contact you soon.

First name

Last name

Phone number

Location (City, State)

Your information will be stored securely and only used for the purposes of identifying people who may be eligible to participate in the HARP and for HARP communications. We will not share your information outside of the HARP study.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.