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Order a Glyphosate Test
Survey
Name
(Required)
First
Last
I am filling this survey out for
Only myself: one sample
Only my child: one sample
Myself & my partner - we have the same answers to below questions
Myself & other family members - we have the same answers to the below questions
If you are the parent or guardian of a study participant who is under 18 years of age and whose data you are providing in this survey, please enter your name
First
Last
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
About You
Age
(Required)
Biological Gender
(Required)
Female
Male
Other
Approx weight
(Required)
Approx height
(Required)
Occupation
(Required)
Education level
(Required)
Less than 12 grades
High school diploma
2-year college degree
4-year college degree
Advanced degree
Sample Type
(Required)
Human Urine
Human Hair
Water
Dog Hair
Cat Hair
Horse Hair
Cow Hair
Other animal hair
Your Surroundings
How would you characterise where you live?
(Required)
Urban
Suburban
Rural
Do you live near a farm
(Required)
Not near a farm
More than 1/2 mile
Within 1/2 mile
Within 1/4 mile
Within 500 feet
Within 100 feet
I live on a farm
Do you live near a golf course, vineyard, park?
(Required)
Not near a farm
More than 1/2 mile
Within 1/2 mile
Within 1/4 mile
Within 500 feet
Within 100 feet
I live in a golf course, vineyard, park
Your Activity
Have you visited a non-organic farm in the last 30 days?
(Required)
No
Yes
Do you work outdoors
(Required)
Rarely / Never
A few times a week
Once a week
Everyday
Do you play golf?
(Required)
Yes
No
Do you play any sports where you make contact with grass? eg Football, soccer
(Required)
Yes
No
Do you visit local or state parks
(Required)
Yes
No
Do you use Round-up or other herbicides (weedkillers) at home or at work?
(Required)
Never
Occasionally
Frequently
If you use Round-up, do you use protective gear?
(Required)
Yes
Sometimes
No
NA: Do not use Round-up
Do you have a lawn care service spray your lawn?
(Required)
Never
Occasionally
Frequently
I don't know what they use
Do your neighbours use Round Up?
(Required)
Never
Occasionally
Frequently
I don't know what they use
Have you recently had direct contact exposure to glyphosate? If so, please enter the number of days since you were exposed:
(Required)
Your Diet
How many servings of fruit and vegetables do you eat per day? (assume 3-4 ounces per serving)
(Required)
Do you consume fresh juices or smoothies?
(Required)
Rarely / Never
Once a week
2-3 days a week
4-5 days a week
Every day
Do you consume beer or wine?
(Required)
Rarely / Never
Once a week
2-3 days a week
4-5 days a week
Every day
Do you consume non-organic whole wheat products (i.e. bread, crackers, shredded wheat, wheat bran, or whole wheat flour)?
(Required)
Rarely / Never
Once a week
2-3 days a week
4-5 days a week
Every day
How often do you consume other non-organic legumes (i.e. beans, peas, lentils, chick peas, hummus)?
(Required)
Rarely / Never
Once a week
2-3 days a week
4-5 days a week
Every day
Do you consume non-organic oats (ie oatmeal, in cookies, muffins or as oat flour)??
(Required)
Rarely / Never
Once a week
2-3 days a week
4-5 days a week
Every day
What percentage of your diet would you estimate is organic?
(Required)
0-10%
10-30%
30-50%
50-75%
75-100%
How many meals do you eat outside of home per week?
(Required)
0-3
4-7
What type of diet do you maintain?
(Required)
Omnivore
Carnivore
Pescatarian (fish + vegetarian)
Vegan
Vegetarian
Mediterranean
Keto
Paleo
Atkins
Low Carb
Do you have any dietary exclusions?
Dairy Free
Nut Free
Gluten Free
Egg Free
Soy Free
Corn Free
Shellfish Free
Sesame Free
No GMO
No FODMAPs
Is most of the water you consume
(Required)
City/Municipal : tap water
Filtered/Purified
Bottled
Mineral Water
Distilled
Spring Water
Rain Water
Well Water
Alkaline
Not Sure
Your Health
How would you describe your overall health
Great
Fair
Poor
Extremely poor
Are you suffering from any of these health problems?
Non-Hodgkin Lymphoma
Endocrine Disruption
Celiac Disease
Leaky Gut
Autism
Cancer
Allergies
Liver Damage
Kidney Damage
Endocrine Problems
Lymphatic Problems
Neurological Problems
Intestinal Problems
Other health issues / details
Consent
(Required)
I agree to the Terms & Conditions, and Consent Form
Standard Terms and Conditions:
By checking “I agree” in the study survey, I indicate that I have read the statement below and choose to enroll in this project, or I am the parent or guardian enrolling a participant who is under the age of 18. This authorization is equivalent to my signature.
Authorizations: I request, authorize and consent to laboratory testing. I understand that test results are strictly informational. Results should not to be used for diagnosis, monitoring, prevention or treatment of disease or impairment of, or the assessment of health. I understand that I should consult with my physician if I have specific questions about my health. I authorize Health Research Institute (HRI) to communicate with me by non-encrypted commercially available email and internet services, unless otherwise specified, to share test results, study updates and other relevant information.
Confidentiality: HRI regards confidentiality as the cornerstone of professional protocol. It is HRI's strict policy to release test results only to the contact person specified by the study participant for that test, and to no one else, unless we have received specific written instructions to do so. This Policy on Confidentiality applies both to test findings and to the names and personal information of all study participants.
Remedies: In the event of a material error by Health Research Institute (HRI) in the performance of analysis HRI’s sole obligation shall be for HRI to either (a) repeat the analysis at HRI's own cost, or (b) refund or credit the invoiced amount. In no event shall HRI Labs' liability in connection with any sale hereunder exceed the price paid for the service in issue.
Indemnification: I indemnify HRI and its directors, officers, employees, and agents from any loss, cost, damage or expense (including reasonable attorneys' fees) from any lawsuit, action, claim, demand or proceeding arising from or associated with, directly or indirectly, HRI’s execution and/or performance of its services.
Consent Form:
Purpose: A great deal has been learned about the impacts of glyphosate and other pesticides (insecticides, herbicides, fungicides, and other agrochemicals) and household and industrial chemicals on health and the environment. Yet, a great deal more needs to be understood. One of the big questions is what are the routes through which people become exposed to these chemicals. Exposure could be happening through many channels, including, the food we eat, the water we drink, the air we breathe, and direct contact in the places where we live, work and play.
This research investigates human exposure to agrochemical and environmental contaminants through analysis of urine samples.
Your participation in this study—both by submitting a urine sample (or multiple samples, in some cases) and by filling out the short online survey—will contribute in a very important way to the depth of data that we can gather. Our goal is to test at least 10,000 subjects and to test these subjects for a number of different agricultural, household and industrial chemicals over time. A subject population of this scope will assure that the results are highly accurate and meaningful.
Procedure: Individual participants, or their medical practitioners, obtain urine samples and mail them to Health Research Institute for analysis. Individual participants also complete a survey online with questions related to possible pathways of exposure to agrochemicals and environmental contaminants. Investigators include urine samples and surveys in the research project and save these for future research. Each subject’s sample and survey will be labeled with the same arbitrary number and stored without any personal identifying information. Because each sample and survey will not be linked to the participant’s name after it is stored, consent to use these cannot be withdrawn after the sample is received.
Health Research Institute will remove identifying information (such as name, email, street address, and payment information provided when sample collection kits are ordered, samples are submitted, or study surveys are completed,) that can identify you prior to using the data for research.
Risks: Sample collection is non-invasive, so no physical health risk is associated with participation. A small number of subjects may have very high levels of agrochemicals or environmental contaminants, which may be emotionally upsetting to them.
Benefits: Participants learn about the levels of specific chemicals in their own physiology. They have the opportunity to learn about the results of the broader research study and to understand their personal levels of chemicals relative to those of the study participants as a whole. They also contribute personally and directly to research that has the potential for improving health and the environment.
Costs: Your decision to participate in the study is voluntary. There is a cost associated with participation. In general, each participant pays for the analysis of his or her own sample.
Confidentiality: This study is for research purposes and all records relating to individual subjects will be kept confidential and will be disassociated from the subject’s sample and survey. Without your express permission, no information will be released or printed that would disclose your personal identity.
Informed Consent: I certify that the research procedures described on this form have been explained to me and that any questions that I have asked have been answered to my satisfaction. I understand the benefits and possible risks (if any) of participating in this research. I know that I may ask now, or in the future, any questions I have about the study or the research procedures. I have been assured that records relating to me will be kept confidential.
I hereby consent to participate in this study.
Do you have any feedback on this survey?
Contact Us: +1 (641) 552-6258
info@hrilabs.org
Terms & Conditions
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