LëtzHBM Survey: I take part in the survey!

What is your name and first name?*

First name Last name

What is your address?*

Street Number City Postal code

What is your phone number?*

What is your e-mail address?*

Are you minimum 18 years old and maximum 39 years old ?*

What is your gender ?*

Have you lived in Luxembourg continuously in the last 5 years?*

Do you have any health problem that makes it hard for you to answer questions or give blood or urine?*

Do you have a child that is minimum 6 years old and maximum 11 years old?*

What is the gender of your child?*

Has this child lived in Luxembourg continuously in the last 5 years?*

Does your child have any health problem that makes it hard for him/her to give blood, urine or hair?*

What is your child's CNS number?*

Do you live in the same house (same address) of your child ?*

In which language do you prefer to be contacted?*

At what time would you prefer to be contacted by our team?*

Name

This field is for validation purposes and should be left unchanged.