Screening Questionnaire Part 1 Answers to Part 1 of this questionnaire (which does not collect any identifiable information such as name/address) will be stored on a secure University of Oxford server. They will be deleted at the end of the study recruitment period for all participants who do not proceed to participate in the study. 1. Is your child under 12 months 6 weeks old? * Yes No 2. What was the gestational age of your child at birth? * < 37 weeks gestational age ≥ 37 weeks gestational age 3. Does your child live in the local area? * Yes No 4. Is your child registered with a GP Practice in the UK? * Yes No 5. Has your child already received their routine 12 - month vaccinations? * Yes No 6. Has your child already received all the routine vaccines recommended at 2, 3 and 4 months of age? * Yes No 6.1. If so, did they receive all these vaccines before they were 6 months old? * Yes No 7. Has your child received any additional vaccines, apart from those recommended in the routine schedule? * Yes No 7.1. Please give details of any additional vaccines they have received * 8. Has your child previously taken part in a clinical study involving a vaccine? * Yes No 8.1. Please give details of any studies your child has previously participated in that have involved a vaccine (if possible: the disease studied; the vaccine given; who organised the study?) * 9. Does your child take any routine medication? * Yes No 9.1. Please give details of any medication they are currently taking. * 10. Has your child ever had a severe allergic reaction? * Yes No 10.1. Please give details of the severe allergic reaction and the cause of it * 11. Has your child had antibody infusions and/or any blood products (such as a blood transfusion) in the last 3 months? * Yes No 12. Does your child have any bleeding disorders? * Yes No 13. Does your child have a history of cancer? * Yes No 14. Has your child’s spleen been removed? * Yes No 15. Does your child have any problems with their immune system? * Yes No 15.1 Please specify. * 16. Has your child ever taken any immunosuppressant medication? * Yes No 16.1 Please specify what medication they are taking * 16.2 How long has/had your child been taking this medication? * 17. Does your child have any other serious long-term illnesses requiring hospital follow-up? * Yes No 17.1 Please specify * 18. Has your child received any vaccinations in the past 28 days, or do they have any planned vaccinations coming up? * Yes No 18.1. Please specify: * 19. Does your child have elective surgery (requiring general anaesthetic or overnight hospital admission) planned? * Yes No 19.1. Please specify: * 20. Does your child live in a household with someone who has severe immunodeficiency, e.g. a household member who is receiving chemotherapy? * Yes No 21. How did you hear about us? * Facebook Instagram Twitter Word of mouth Poster Email Circular Online Search Daily Info Invitation letter Other 21.1 If other, please specify * Thank you for your interest in our study. Based on your responses, you may be eligible to participate. A second part to this questionnaire will follow shortly. Thank you for your interest in our study. Based on your responses, you might be eligible to participate. A second part to this questionnaire will follow shortly. Thank you for your interest in our study. Based on your responses, you are not eligible to take part in this study. Screening Questionnaire Part 2 22. To enable us to include your child in the study, we would need to gather further information about your child’s medical history. This would be used to help decide if your child is eligible to take part in the study. Giving your consent means that you are happy for us to store and use your contact details and your child’s personal information for the purposes of this study. Information will be stored in password protected files on a secure University of Oxford server, in accordance with the UK GDPR and Data Protection Act. Further information can be found at: https://compliance.web.ox.ac.uk/individual-rights I agree for University Hospital Southampton NHS Foundation Trust to record my contact details, and my child’s personal information, and information about their medical history. * Yes No 23. Are you happy to provide details of your child’s medical history? * Yes No 24. Please provide details of any past or current medical problems of your child. * 25. I agree for University Hospital Southampton NHS Foundation Trust to contact me by email, telephone or post for the purposes of this study. * Yes No 26. I agree for University Hospital Southampton NHS Foundation Trust to contact my child’s GP practice or Child Health Information Services (CHIS) to request information about my child’s medical and/ or immunisation history. * Yes No To ensure that your child is eligible to take part in this study we need to know which 6-in-1 vaccine your child received for their baby immunisations. If you are interested in your child taking part, please email a photo of your child’s baby immunisations from their “red book” to 6in1vaccinestudy@uhs.nhs.uk. Please write “The 6-in-1 Part 2 Vaccine Study” as the title of your email and include your child’s name in the message. The photographs below show what to do. Thank you for your interest in our study. Based on your responses, your child may be eligible to participate. Please complete the questions below. Please read the study information booklet. We will arrange to contact you. Thank you for your interest in our study. Based on your responses, you are not eligible to take part in this study. 1. What is your child’s first name? * 2. What is your child’s last name? * 3. What is your child’s date of birth? * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20202021202220232024202520262027 4. What is your child’s sex? * Male Female 5. What is your first name? * 6. What is your last name? * 7. Are you over 18 years of age and the child’s parent or legal guardian? * Yes No 8. What is your e-mail address? * 9. What is your phone number? * 10. What is your full address including your postcode? * 11. What are your child’s GP Practice details (including GP Practice name, address, phone number and e-mail)? * 12. What is your child’s NHS number? * 13. What is the best time to call you (please specify week day, am/ pm) to discuss the study and book a visit? * 14. What is the best time for your visit (please specify week day, am/ pm)? * Math question * 6 + 10 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
