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Smokers > Options for Quitting Smoking
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Complete This Form to Volunteer for a Smoking and Genetics Study

To determine possible new treatments to help people quit smoking, we are recruiting 450 people in both the Madison and Milwaukee areas for this study on how genetics may influence tobacco use. You must be an adult 20 years old or older and a former smoker. You could earn $50 in gift cards.

    • This study will require participants to travel to either downtown Milwaukee or the near-west side of Madison for a one-time, one-to-two hour visit.
    • Please read all of these instructions before completing the form.
    • We need at least one phone number to contact you.
    • The two “how heard” fields help us determine how best to recruit participants for future important health research.
    • All of this information remains confidential. We do not share this information with any other individuals or organizations.

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 E-mail Address

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

Indicate Your Preferred Location:

Madison     Milwaukee
     

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


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