COVID-19 Samples Questionnaire

Protocol Title: “Collection of human biological samples for the research and development of COVID-19 detection assays”

You are being asked to participate in a medical research study. Your participation in this research study is strictly voluntary, meaning that you may or may not choose to take part. To the extent permitted by applicable laws and regulations, the records identifying you will not be made publicly available.

Name: *

Today’s date *

Birthdate: *

Age (years): *

Sex (choose one): *

Male

Female

Race (choose all that apply):

American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”

Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.”

Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Symptoms

Date of COVID-19 symptom onset *

Last date of COVID-19 symptoms *

How were you diagnosed with COVID-19? *

PCR (most common, detects viral nucleic acid)

Antigen test (detects viral protein)

Date of test *

Date results received *

A copy of your COVID-19 test results (using a nasal or throat swab) is required prior to sample collection. Will you be able to provide documentation that you took this test? *

Yes

Which samples do you wish to donate? (check all that apply) *

Saliva

Fingerstick blood

Venipuncture blood (70 cc)

Have you given blood within the last 2 months? *

Yes

If so, when?

If so, how much? (in tablespoons or cc)

Symptom Checklist

GENERAL

Fever *

Chills *

Tiredness *

Body Aches *

Rash *

RESPIRATORY

Runny Nose *

Shortness of Breath *

Cough *

Pneumonia *

GASTROINTESTINAL

New Loss of Taste *

Loss of Appetite *

Sore Throat *

Nausea/Vomiting *

Diarrhea *

NEUROLOGIC

Headache *

Weakness/Loss of Speech *

Blurred Vision *

Eye Infection/Inflammation *

CARDIAC/HEART

Chest Pain *

New Onset Irregular Heartbeat *

Heart Attack *

By checking this box and typing my name below, I am electronically signing this questionnaire confirming that, to the best of my knowledge, the information that I have provided in this questionnaire is correct. *

Signature (type name): *

Date *

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