1. Is your child aged between 12 and 15½ years? * Yes No 2. Are you and your child able and willing to attend the study site for up to 5 visits over 7 months? * Yes No 3. Is your child registered with a GP Practice in the UK? * Yes No 4. Has your child previously received a vaccine for COVID-19? * Yes No 5.How many doses? * Two One 6. Did your child receive the Pfizer vaccine? * Yes No 7.1: What dates did your child receive the Pfizer vaccine? (Dose 1) * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year202020212022 7.2: What dates did your child receive the Pfizer vaccine? (Dose 2) * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year202020212022 8. Has your child been advised to have more than two doses of COVID-19 vaccine? (This could either be because of a health condition they have, or because someone they live with has impaired immunity.) * Yes No 9. Has your child previously taken part in a clinical study involving a vaccine? * Yes No 10. 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)? * 11. Is your child currently participating in any COVID-19 serological survey studies and/or prophylactic drug trials? * Yes No 12. Does your child take any routine medication? * Yes No 13. Please give details of any medication they are currently taking * 14. Has your child ever had a severe allergic reaction? * Yes No 15. Has your child had antibody infusions and/or any blood products (such as a blood transfusion) in the last 3 months? * Yes No 16. Does your child have any bleeding disorders? * Yes No 17. Does your child have a history of congenital heart disease? * Yes No 18. Does your child have a history of cancer? * Yes No 19. Has your child’s spleen been removed? * Yes No 20. Does your child have any problems with their immune system? * Yes No 21. Please specify * 22. Does your child take any immunosuppressant medication? * Yes No 23. Please specify what medication they are taking. * 24. How long has your child been taking this medication? * 25. Is your child under the care of a psychiatrist? * Yes No 26. Does your child have any other serious long-term illnesses requiring hospital follow-up? * Yes No 27. Please specify: * 28. Has your child received any vaccinations in the past 7 days, or do they have any planned vaccinations coming up? * Yes No 29. Does your child have elective surgery (requiring general anaesthetic or overnight hospital admission) planned? * Yes No 30. How did you hear about us? * - Facebook - Instagram - Twitter - Word of mouth - Poster - Email Circular - Online Search - Daily Info - Other 31. Please specify: * 32. Are you happy to provide details of your child’s medical history? * Yes No 33. Please provide details of any past or current medical problems of your child. * 34. Do you consent for us to contact your GP with any further questions we may have about your child’s medical history? * Yes No 35. I agree for the Oxford Vaccine Group to record our personal information and information about my child’s medical history. I agree to be contacted by the Leeds Teaching Hospitals NHS Trust for the purposes of this trial. * Yes No 36. I consent for Leeds Teaching Hospitals NHS Trust to contact my child’s General Practitioner and to obtain details of my child’s medical history from them. * Yes No Thank you for your interest in our study. Based on your responses, your child may be eligible to participate. Please complete the questions below. We will send you more information about the study and arrange to contact you by phone. 37. What is your child’s first name? * 38. What is your child’s last name? * 39. What is your child’s date of birth? * 40. What is your child’s gender? * Male Female 41. What is your first name? * 42. What is your e-mail address? * 43. What is your phone number? * 44. What is your address? * 45. What is your postcode? * 46. What are your child’s GP Practice details? * 47. What is your child’s NHS number (if known)? You can find out your NHS number by clicking on this website link and filling in your details: https://www.nhs.uk/nhs-services/online-services/find-nhs-number * 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. Math question * 16 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
