Is your child aged 6 – 15 years? * Yes No Are you or either parent/guardian a member of staff at the Oxford Vaccine Group? * Yes No Do you live in the Southampton? (see map below) * Yes No Has your child previously received a vaccine for Meningitis B? * Yes No Is your child registered with a GP Practice in the UK? * Yes No Does your child take any routine medication? * Yes No Please give details of any medication you are currently taking: * Has your child ever been diagnosed with COVID-19? * Yes No Has your child ever been diagnosed with Kawasaki disease? * Yes No Has your child had antibody infusions and/or any blood products (such as a blood transfusion) in the 3 months preceding involvement in this trial? * Yes No Does your child have any bleeding disorders? * Yes No Does your child have a history of cancer? * Yes No Does your child have any problems with your immune system? * Yes No Please specify: * Does your child take any immunosuppressant medication? * Yes No Please specify what medication they are taking: * Is your child under the care of a psychiatrist? * Yes No Has your child 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). * Is your child currently participating in any COVID-19 serological survey studies and/or prophylactic drug trials? * Yes No Has your child received any vaccinations in the past 30 days or do you have any planned vaccinations coming up? * Yes No Has your child ever had a severe allergic reaction? * Yes No Does your child have any other serious long-term illnesses requiring hospital follow-up? * Yes No Please specify: * We will request urinary pregnancy tests from all females aged 11 and over prior to vaccination for this study and request that any sexually active females avoid pregnancy for the duration of this trial. Please tick yes to acknowledge this * Yes No How did you hear about us? * Facebook Instagram Twitter Word of mouth Poster Email Circular Online Search Daily Info Other Please specify: * Thank you for your interest in our study. Based on your responses, your child may be eligible to participateA second part to this questionnaire will follow shortly Thank you for your interest in our study. Based on your responses, your child might be eligible to participate. A second part to this questionnaire will follow shortly. Are you happy to provide any details of your child’s medical history? * Yes No Please provide details of existing medical history below * Do you consent for us to telephone you if we have further questions? * Yes No Thank you for your interest in our study. Based on your responses, your child is not eligible to take part in this study. If you are interested in hearing more about our other studies, you can sign up to our monthly newsletter here: https://newsletter.ovg.ox.ac.uk/OVG/paedList/?p=subscribe&id=1 . Do you consent for us to contact your GP with any further questions we may have about your medical history? * Yes No Thank you for your interest in our study. Based on your responses, your child may be eligible to participate. Please complete the below questions and we will be in touch with more information about the study and to arrange an initial phone call. Thank you for your interest in our study. Based on your responses, your child might be eligible to participate. Please complete the below questions and we will be in touch if your child is eligible or if we have any more questions. Thank you for your interest in our study. Based on your responses, you are not eligible to take part in this study. If you are interested in hearing more about our other studies, you can sign up to our monthly newsletter here: INSERT WEBLINK What is your child’s first name? * What is your child’s last name? * What is your name? * What is your child’s date of birth? * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 What is your email address? * What is your phone number? * What is the first part of your postcode (e.g. OX4)? * What are your child’s GP Practice details? * Math question * 4 + 7 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
