UW-CTRI: Enrollment Form for a Stop-Smoking Research Study

Complete This Form to Participate in a Quit-Smoking Study in Milwaukee

This study will require participants to visit the downtown Milwaukee area.
Please read all of these instructions before completing the form.
We need at least one phone number to contact you.
The last five pieces of information help us determine how best to recruit participants for important health research. This information is not shared with anyone else.
Once you submit your information, our staff will make every effort to contact you as soon as possible. However, due to the volume of interest in this study, it may be a few weeks before you hear from us. Thank you for your patience!

Your full name
A daytime phone number (including the area code)
An evening phone number (including the area code)
A cell phone number (including the area code)
The best times to reach you
Your Email Address	Your email address will only be used to contact you regarding our stop smoking study and will not be sold or given away at all.
How you heard about us
If it was on TV, radio or in the newspaper, please let us know what station or what paper OR if you chose 'Other', specify here.
Your City
Your Zip Code

Thank you for your interest and we look forward to speaking with you!