I agree for the Oxford Vaccine Group on behalf of St George's University Hospitals NHS Foundation Trust to record my personal information and information about my medical history. I agree to be contacted by the Southampton General Hospital for the purposes of this trial. * Yes No Which age group do you fall into? * Under 18 years of age 18 years to 44 years of age 45 years of age or older Are you pregnant? * Yes No Are you pregnant with more than one baby in this pregnancy? * Yes No At what stage of your pregnancy are you? * 0 to 12+6 weeks 13 to 36+0 weeks 36+1 weeks and above Have you had a COVID-19 vaccine? * 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 sheet provided at: https://vaccine.ac.uk/preg-cov-trial Please read the sheet 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 (with the exception of anti-D immunoglobulin)? * 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 Do you have an allergy to 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 allergic to latex? * Yes No Have you received immunosuppressive chemotherapy or radiotherapy for treatment of cancer in the last 6 months? * 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 had any problems with uncontrolled blood pressure in this pregnancy so far? * Yes No Have you had any problems with uncontrolled gestational diabetes in this pregnancy so far? * Yes No Have you had a history of a preterm delivery (before 34 weeks), a stillbirth delivery or a neonatal death in a previous pregnancy? * Yes No Have you previously had a baby with a known genetic disorder or major congenital problem? * Yes No Would you be able to attend for a minimum of nine to twelve visits over the course of the trial? * Yes No Would you be happy for your baby to be part of the trial after delivery? This will involve trial visits combined with yours and in most cases only one blood test for your baby * 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 Have you received any vaccine other than the influenza ('flu) or pertussis (whooping cough) vaccine in the last 30 days? Do you plan to receive any vaccine other than the influenza ('flu) or pertussis (whooping cough) 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 for your interest in the trial. To 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 trial. 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 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 Hospital Southampton NHS Foundation Trust 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 Hospital Southampton NHS Foundation Trust to contact my General Practitioner and to obtain details of my medical history from them. I also consent to the University Hospital Southampton NHS Foundation Trust 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. What is your title? E.g. Mr, Mrs, Miss, Ms, 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 What is your gender? * Female Non-binary or transgender What is your NHS number (if known). You can find out your NHS number by clicking on this website link and filling in your details: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/ 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: 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: Indian ASIAN: Pakistani ASIAN: Bangladeshi ASIAN: Chinese ASIAN: Any other Asian background, please describe AFRICAN, CARIBBEAN OR BLACK: African AFRICAN, CARIBBEAN OR BLACK: Caribbean AFRICAN, CARIBBEAN OR BLACK: Any other Black/African/Caribbean 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? * What is your estimated date of delivery (EDD)? Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20222023202420252026 Do you take any regular medication? * Yes No Please list all here, and please give the name of the condition that you take the medication for * Do you have any mental health conditions? * Yes No Please list all here * Do you have any medical conditions that have not already been recorded above? Please record even if this is a condition that you consider to be minor or not a problem at present * Yes No Please list here * Have you had any problems in this pregnancy so far? * 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 * Thank you for your interest in joining this study. We may be in touch to discuss further arrangements with you. Please note that we often receive a high volume of responses, and not all people who respond will be able to join the study. 1 Start 2 Complete Math question * 6 + 12 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
