COVID-19 Vaccine Study 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 is strictly voluntary, meaning that you may or may not choose to take part at any time. To the extent permitted by applicable laws and regulations, the records identifying you will not be made publicly available.

COVID-19 Vaccine Study Questionnaire


Sex: *
Race (choose all that apply): *
I will notify the study personnel if I provide blood or any other blood component (plasma, cells, platelet-rich plasma) prior to a scheduled appointment: *
I will notify the study personnel if I get diagnosed with COVID-19 prior to a scheduled appointment: *

COVID-19 Vaccine History

If you haven’t been vaccinated yet, we can collect your samples before and after each vaccine shot. If you have received 1 of 2 vaccine doses, complete the questions below as though you have completed both doses; we will collect your samples only after you receive your last dose.

I am scheduled to receive an FDA-approved vaccine within the next 2 weeks: *
Was the last dose less than 30 days ago?: *
I can provide documentation of the vaccination schedule: *
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. *

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