COVID-19 Samples Questionnaire

COVID-19 Patient 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.

Sex (choose one): *
Race (choose all that apply):


How were you diagnosed with COVID-19? *
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? *
Which samples do you wish to donate? (check all that apply) *
Have you given blood within the last 2 months? *

Symptom Checklist






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. *