1- Which age group do you fall into: 18- 55 years or 56 – 69 years or 70 years and older * 18- 55 years 56 – 69years 70 years and older 2- Do you live or work in Bristol Area? see map below * Yes No 3- Are you registered with a GP Practice in the UK? * Yes No 4- Are you currently taking any medication? * Yes No Please give details of any medication you are currently taking * 5- Are you currently under the care of, or waiting for an appointment with, a hospital specialist? * Yes No Please give details of any specialist care or appointments * 6- Have you had a confirmed diagnosis of COVID19 (diagnosed by a health care professional)? * Yes No 7- Are you taking anticoagulants (blood thinners apart from aspirin or clopidogrel) * Yes No 8- Do you have any bleeding disorders? * Yes No 9- Are you currently being treated for cancer? * Yes No 10- Have you received a blood transfusion or blood products within the last 3 months? * Yes No 11- Have you ever had a severe allergic reaction? * Yes No 12- Do you have any problems with your immune system? * Yes No Please specify * 13- Have you taken any immunosuppressant medication in the last 6 months? * Yes No Please specify what medication you are taking * 14- Are you under the care of a psychiatrist? * Yes No 15- Have you previously taken part in a clinical trial involving a vaccine? * Yes No Please give details of any trials you have previously participated in that have involved a vaccine (if possible: the disease studied, vaccine given, who the study was with). * 16- Are your currently taking part in any COVID-19 antibody (serological)survey studies? * Yes No 17- Are you currently taking part in any COVID-19 preventative (prophylactic) drug trials? * Yes No 18- Have you received any vaccinations in the past 30 days or do you have any planned vaccinations coming up? * Yes No 19- Are you currently pregnant, breastfeeding or planning on becoming pregnant over the next 6 months? * Yes No 20- How did you hear about us? * - Select -FacebookInstagramTwitterWord of mouthPosterEmail CircularOnline SearchDaily InfoDirect mail outOther Pplease specify * Thank you for your interest in our study. Based on your responses, you are eligible to proceed to screening. Please complete the below questions and we will be in touch with more information about the study and to arrange a screening appointment. Thank you for your interest in our study. Based on your responses, you are eligible to proceed to screening. Please complete the below questions and we will be in touch with more information about the study and to arrange a screening appointment. Thank you for your interest in our study. Based on your responses, you are not eligible to take part. 1. What is you first name? * 2. What is your last name? * 3. What is your date of birth? * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year18241825182618271828182918301831183218331834183518361837183818391840184118421843184418451846184718481849185018511852185318541855185618571858185918601861186218631864186518661867186818691870187118721873187418751876187718781879188018811882188318841885188618871888188918901891189218931894189518961897189818991900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 4. What is your ethnic origin? * - Select -White - BritishWhite – IrishWhite – OtherBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – Other Black backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – ChineseAsian or Asian British – Other Asian backgroundMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed - OtherGypsy or TravellerArabOtherPrefer not to say Please specify * 5. What is your email address? * 6. What is your phone number? * 7. What is the first part of your postcode (e.g. BS1)? * 8. What are your GP Practice details? * 9. Are you a: 1- Hospital Worker (including clinical staff, cleaners, porters, but excluding office workers). 2- Social Care worker and/or care home worker (excluding office only staff). 3- Primary Care Worker (including reception, but excluding office only staff). 4- Other healthcare workers (including paramedics) * Yes No Please give details of what area, department or specialty you work in * 10. Are you in contact with any individuals with confirmed or suspected COVID-19? * Yes No 11. What is your occupation * 12.Are you employed in a job that means you cannot work from home? * Yes No Not Applicable 13. I agree that a researcher from the North Bristol NHS Trust or University Hospitals Bristol and Weston NHS Foundation Trust can contact me via phone to discuss details of my medical history to assess my eligibility to participate in the trial and if enrolled will go towards my baseline health records. I understand that a unique participant ID number will be allocated to me and used to record my medical history on a secure server and kept for the duration of the study. Name [Participant enters name] * 14- Would you prefer to attend clinics based at the Southmead Hospital or at the Bristol Royal Infirmary? * Southmead Hospital Bristol Royal Infirmary Math question * 11 + 1 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
