Which age group do you fall into? * 18 – 30 years of age 31 years of age or older Do you work directly for the research team that are conducting this trial? * Yes No Do you live close enough to University Hospitals Dorset NHS Foundation Trust (Bournemouth) to attend 5 study visits over a period of eight months? * Yes No How many doses of a COVID-19 vaccine have you had? * Two doses Less than two doses More than two doses Thank you, but unfortunately you need to be within easy traveling distance of a study site. Please see https://www.covboost.org.uk/participate-substudy to check if there is a trial site nearer where you live Did you receive your second dose of a COVID-19 vaccine at least three months ago? * Yes No Did you receive either Pfizer or Moderna vaccines as your first two doses? * Yes No Have you read the participant information sheet? * Yes No Unfortunately we can’t consider you for this trial until you have read the participant information leaflet provided at : https://covboost.web.ox.ac.uk/participate-bournemouth-substudy#pis Please read the leaflet and then resume this questionnaire if you are still interested in participating in the trial 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 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? Includes anaphylaxis and angioedema (facial swelling and difficulty breathing), or have you been advised by a medical professional to carry an adrenaline auto-injector * 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 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 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. If you decide that you do not want to give your consent for these items your details will not be recorded and the research team will not be able to contact you. I agree for the Oxford Vaccine Group on behalf of University Hospital Southampton NHS Foundation Trust to record my personal information and information about my medical history. I agree to be contacted by the University Hospitals Dorset NHS Foundation Trust (Bournemouth) 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 University Hospitals Dorset NHS Foundation Trust (Bournemouth) to contact my General Practitioner and to obtain details of my medical history from them. I also consent to the University Hospitals Dorset NHS Foundation Trust (Bournemouth) 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 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 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, please visit nhs.uk/researchcontact 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 Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Which of the following options best describes how you think of yourself? * Woman (including trans woman) Man (including trans man) Non-binary In another way Is your gender identity the same as the gender you were assigned at birth? * Yes No What is your occupation? * Health and social care setting workers Drivers and transport workers Retail workers in essential shops and branches (e.g. food, chemists, banks) Hospitality/retail workers in non-essential shops and branches Cleaning and domestic workers Public safety workers (e.g. police, fire services, security) Religious workers Construction workers and labourers Other occupation Unemployed Student Retired If other, please specify * What is your ethnic origin * WHITE: English/Welsh/Scottish/Northern Irish/British WHITE: White Irish WHITE: Gypsy or Irish Traveller WHITE: Any other White background, please describe MIXED OR MULTIPLE ETHNIC GROUPS: White and Black Caribbean MIXED OR MULTIPLE ETHNIC GROUPS: White and Black African MIXED OR MULTIPLE ETHNIC GROUPS: White and Asian MIXED OR MULTIPLE ETHNIC GROUPS: Any other Mixed/Multiple ethnic background, please describe ASIAN OR ASIAN BRITISH: Indian ASIAN OR ASIAN BRITISH: Pakistani ASIAN OR ASIAN BRITISH: Bangladeshi ASIAN OR ASIAN BRITISH: Chinese ASIAN OR ASIAN BRITISH : Any other Asian background, please describe BLACK/AFRICAN/CARIBBEAN/BLACK BRITISH: African BLACK/AFRICAN/CARIBBEAN/BLACK BRITISH: Caribbean BLACK/AFRICAN/CARIBBEAN/BLACK BRITISH: Any other Black / African / Caribbean / Black British background, please describe OTHER ETHNIC GROUP: Arab OTHER ETHNIC GROUP: Any other ethnic group, please describe Prefer not to give If other, please specify * How will you primarily attend your clinic visits? * Solely reliant on public transport Car Motorbike Bicycle Walking 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 * 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 * What vaccines did you receive as your first two doses? * Pfizer Moderna What date did you receive your second dose of Pfizer or Moderna COVID-19 vaccine? * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Have you ever had a positive laboratory confirmed COVID-19 PCR test? * Yes No If you are happy to, please let us know your NHS number so that the study team can confirm what vaccines you have received and your vaccination dates ahead of your screening visit. This question is optional and you do not need to provide this here if you do not wish to. * Math question * 1 + 17 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
