Date - Nationwide Children's Hospital 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Screening Date in the designated field. Ensure that the date is on or after March 1, 2018.
3. Fill in your First Name and Last Name accurately. This information is crucial for identification purposes.
4. Provide your Date of Birth and Age. This helps in assessing eligibility and health metrics.
5. Indicate your Sex at birth by checking either 'M' or 'F'.
6. Complete the Gender Identity section as applicable.
7. If you are an employee, check the appropriate box and enter your Employee ID number along with your email address.
8. For spouses, check the relevant box and provide the last four digits of their Social Security Number.
9. Answer whether you use tobacco or nicotine products. If yes, be aware of potential surcharges; if no, ensure to submit blood cotinine test results if not already done.
10. Fill out the health care provider's name and ensure they sign off on the form before submission.

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