Are you aged between 50 and 70 inclusive? * Yes No Can you attend regular visits at the study site (Liverpool)? * Yes No Have you read the participant information sheet( PIS Link)? * Yes No Are you registered with a GP practice in the UK? * Yes No Are you currently pregnant, breastfeeding or planning on becoming pregnant in the next 12 months? * Yes No Have you had at least TWO doses of the Oxford/AstraZeneca vaccine? * Yes No, I have had NO doses of the Oxford/AstraZeneca Vaccine No, I have had ONE dose only of the Oxford/AstraZeneca Vaccine Unsure Do you have HIV infection, asplenia, severe recurrent infections? * Yes No Within the last 12 months, have you had treatment with immunosuppressive drugs? * Yes No Within the last 12 months, have you needed treatment with oral or injected steroids for 2 or more weeks? * Yes No Do you have a history of blood clots (deep vein thrombosis, pulmonary embolus, heart attack, stroke or other major blood clot?) * Yes No Have you ever had cancer (except for basal cell carcinoma or cervical cancer in situ)? * Yes No Thank you for your interest in the trial. We would like to gather some initial information about your medical history here 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 UK GDPR and Data Protection Act. Further information can be found at: https://compliance.web.ox.ac.uk/individual-rights 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. 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 study team for the purposes of this trial. * Yes No Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored. 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 Year19521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977 What is your gender? * Male Female Non-binary or transgender Other If other, please specify * 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 (that involve receiving a medication, vaccine or providing blood samples)? * Yes No If yes, please detail * Thank you, but unfortunately you need to be within easy traveling distance of a study site. Unfortunately we can’t consider you for this trial until you have read the participant information leaflet provided at: https://trials.ovg.ox.ac.uk/trials/sites/default/files/MERS003_PIS_V2.1_... Please read the leaflet and then resume this questionnaire if you are still interested in participating in the trial. Math question * 2 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
