Which age group do you fall into? * Under 50 years of age 50 years of age or older Do you work for the research team that are conducting this trial? * Yes No Do you live within the areas indicated on the site map and would you be able to travel easily to London? * Yes No Have you read the participant information sheet? * Yes No Are you registered with a GP practice in the UK? * Yes No Have you had a blood transfusion or received any blood products (e.g. immunoglobulins) in the last three months? * Yes No Do you have or have you ever had an auto-immune neurological disorder? For example, multiple sclerosis, Guillain-Barre syndrome, transverse myelitis. Note that Bell’s palsy is not included in this group. * Yes No Have you taken any immunosuppressant medication (other than steroid creams or steroid tablets for fewer than 14 days) in the last six months? * Yes No Do you have any medically-diagnosed problems with your immune system? E.g. asplenia or immunodeficiency condition? * Yes No Have you ever had a severe allergic reaction? (Anaphylaxis) * Yes No Are you aware that you have an allergy to any of the component of the COVID vaccines used in this study, including polyethylene glycol/macrogol (PEG)? (PEGs are a group of known allergens commonly found in medicines, many household products and cosmetics, and are contained in the BNT162b2 (Pfizer/BioNTech) vaccine. Known allergy to PEG is very rare.) * Yes No Are you currently pregnant, breastfeeding or planning on becoming pregnant in the next 12 months? * Yes No Do you have or are you being treated for any cancer? (“carcinoma in situ” of the cervix and “basal cell carcinoma” of the skin, do not count for this question) * Yes No Do you have any bleeding disorders or take any blood thinning (anticoagulant) medication, or have you ever had? Aspirin does not count * Yes No Have you ever had bruising or bleeding from an injection or blood-taking that was severe enough to need medical attention? * Yes No Do you have any current alcohol or drug dependency? * Yes No Are you booked for any major surgery in the next year? * Yes No Would you be able to attend five to nine visits at the London over a year? * Yes No Have you ever tested positive for COVID-19 infection or had an antibody test that showed you had antibodies to COVID-19? * Yes No Have you ever had any COVID-19 vaccine? * Yes No Have you ever previously received a ChAdOx1 vectored vaccine? Please click on link to view previous OVG/Jenner adenovirus-vectored vaccine studies that you might have taken part in if you are not sure. * Yes No Have you been involved in another research trial that involved an investigational product in the past 12 weeks? * Yes No Are you currently taking part in any drug trials related to the prevention of COVID-19? * Yes No Would you agree to not donate blood for one year whilst in the trial? * Yes No Have you received any vaccine other than the influenza ('flu) or pneumococcal vaccine in the last 30 days? Do you plan to receive any vaccine other than the influenza ('flu) or pneumococcal vaccine in the next 30 days? * Yes No Thank you for your responses. You may be eligible to participate in this trial. Please proceed to the next section where we will ask for your consent to record more medical information. Thank you, but unfortunately you need to be within easy traveling distance of a study site. Please see https://comcovstudy.org.uk/ to check if there is a trial site nearer where you live Unfortunately we can’t consider you for this trial until you have read the participant information leaflet provided at : https://comcovstudy.org.uk/files/com-covpisv1228-jan-2021sgulpdf Please read the leaflet and then resume this questionnaire if you are still interested in participating in the trial Thank you for your interest in the trial. In order to help manage the risks of COVID-19 we are trying to minimise the time volunteers spend at our screening visits. To help with this, we would like to gather information about your medical history here. This will be used to help decide if you are eligible to take part in the study. Giving your consent means that you are happy for us to store and use your personal information for the purposes of this trial. Information will be stored in accordance with the GDPR and Data Protection Act. I agree for the Oxford Vaccine Group to record my personal information and information about my medical history. I agree to be contacted by the Oxford Vaccine Group for the purposes of this trial. * Yes No We would also like to have the option of contacting your GP if there is any information about your medical history that we need to clarify. We would also contact them to let them know you are in the trial should you be enrolled, and we would want to keep them updated (if needed) about your health during the trial. We would need your consent to do this. I consent for the Oxford Vaccine Group to contact my General Practitioner and to obtain details of my medical history from them. I also consent to the Oxford Vaccine Group making my General Practitioner aware of any new information, gathered through the trial, which is felt to be relevant to my medical care. I also consent for my general practitioner to be notified if I am enrolled in the trial. * Yes No Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored. If you are interested in hearing more about our other studies, you can sign up to our newsletter here http://newsletter.ovg.ox.ac.uk/OVG/lists/?p=subscribe&id=1. What is your title? E.g. Mrs, Miss, Ms, Mr, Dr, Prof * What is your full first name (as it appears on your passport)? * What is your last name? * What is your date of birth? * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 What is your gender? * Male Female Non-binary or transgender What is your occupation? * - Select -Health and social care setting workersDrivers and transport workersRetail workers in essential shops and branches (e.g. food, chemists, banks)Hospitality/retail workers in non-essential shops and branchesCleaning and domestic workersPublic safety workers (e.g. police, fire services, security)Religious workersConstruction workers and labourersOther occupationUnemployedStudentRetired If other, please specify * What is your ethnic origin * - Select -White English, Welsh, Scottish, Northern Irish or BritishWhite IrishGypsy or Irish TravellerAny other White background, please describeWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed/Multiple ethnic background, please describeIndianPakistaniBangladeshiChineseAny other Asian background, please describeAfricanCaribbeanAny other Black/African/Caribbean background, please describeArabAny other ethnic group, please describePrefer not to give Please specify other ethnic origin * How will you primarily attend your clinic visits? * - Select -Solely reliant on public transportCarMotorbikeBicycleWalking What is your email address? * What is your phone number? * What is your address? * What is your postcode? * What are your GP practice details? * Do you have any medical conditions? * Yes No Please list all here * Do you have any mental health conditions? * Yes No Please list all here * Are you currently taking any medication? * Yes No Please list here * Applicable only to volunteers who have ever been able to become pregnant: Are you post-menopausal (must have had no periods for at least 12 months, must not be on any hormonal contraception and be over the age of 50) * Yes No Not applicable Are you currently using any form of contraception and would you agree to continue using this for the duration of the trial? * Yes No What is your method of contraception? Please select option. Please note periodic abstinence and the withdrawal method are not acceptable methods of contraception * - Select -Oral, injected or implanted hormonal contraception e.g. “the pill”, “mini-pill”, “depot injection” or “implant”Intrauterine device (IUD) or intrauterine system (IUS) (commonly referred to as having “a coil”)Have had a total hysterectomy (surgical removal of the womb)Bilateral tubal occlusion (commonly referred to as “tube-tie” or “female sterilisation”)Barrier methods of contraception (condom or occlusive cap [diaphragm] with spermicide)Partner has had male sterilisation (vasectomy) - as long as this is your only partnerPractice true abstinence – as long as this is your preferred and usual lifestyle Do you have any allergies? (All allergies including food, medication and insect bites/stings) * Yes No If yes, please detail * Are you currently taking part in any other research studies? * Yes No If yes, please detail * Have you ever received a vaccine as part of a research study or trial? * Yes No If yes, please detail * Math question * 1 + 2 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
