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COVID-19 Survey

Unite Against Covid-19

Across the country, people are needed in the battle against COVID-19.

COVID-19 survey: Unite Against Coronavirus

Adults aged 18 and older may be eligible to participate in local COVID-19 clinical trials that are enrolling now.

If you qualify you may:

See a physician or medical staff at no cost
Receive compensation for time and travel

Complete this short COVID-19 survey to see if you qualify

Please tell us about yourself so that we can find suitable study locations near you. All the information you complete will remain private.

First Name

Last Name

Email

Primary Phone

Mobile Phone

Address

Apt. / Ste.

City

Zip Code

We need this information calculate your body mass index (BMI).

Height (Feet)

Height (Inches)

Weight (lbs)

Date of Birth

Gender

Male Female Other

Please choose the race and/or ethnicity that describes yourself. Choose all that apply:

Hispanic or Latino American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Prefer not to say

Do you work in any of the following industries/occupations?

Retail Healthcare Food service (catering) Public/community official (for example, a police officer) Nursing home/long-term care facility Manufacturing or meat packing plant Transportation (for example, a taxi driver or bus driver) Other occupation that puts me at high risk of exposure to COVID-19 None of the above

Do you currently have COVID-19, or have you tested positive for COVID-19 in the past?

Yes No Not sure

Do you have any of the following health conditions?

A suppressed or compromised immune system (for example, frequent severe infections or a condition that prevents the body from fighting infections and diseases) Asthma Bleeding disorder Cancer (other than prostate cancer that has not spread, and fully treated non-melanoma skin cancer or cervical cancer) Chronic liver disease (including cirrhosis) Chronic obstructive pulmonary disease (COPD) Diabetes (including type 1, type 2, or gestational) Guillain-Barré syndrome (a condition in which the body’s immune system attacks the nerves, causing problems such as numbness, weakness, and pain) Any other condition that results in damage to the protective covering (myelin sheath) that surrounds nerves in your brain, eyes, and spine (e.g. multiple sclerosis, optic neuritis [inflammation of the nerve to the eyes], transverse myelitis [inflammation of the spinal cord]) Heart disease High blood pressure Obesity None of the above I’m not sure

Have you received/used any of the following?

Any vaccine (except an approved flu vaccine) within the past 30 days An experimental vaccine (including COVID-19 vaccine) within the past 6 months Blood transfusions within the past 3 months Cancer treatments (including chemotherapy, immunotherapy, and radiotherapy) within the past 6 months Experimental products indicated for the treatment or prevention of COVID-19 Immunosuppressant medication in the past 6 months (other than inhaled steroids, steroids as a cream, or taken by mouth for a short duration) Steroid medications (corticosteroids, a type of anti-inflammatory medication) by mouth or injection for more than 14 days within the past 6 months None of the above I'm not sure

Are you a smoker?

Yes No

If smoker, please tell us the brand of cigarettes and amount you smoke per day

Do you live in a nursing home or long-term care facility?

Yes No

Do you have a device with access to the internet (e.g. smartphone, computer, or tablet) that can be used to complete some study assessments electronically? This will not affect your eligibility for the study.

Yes No

Interested in other studies?

Alzheimer's Disease Arthritis Asthma Cancer Cardiovascular Diseases Chronic Obstructive Pulmonary Disease (COPD) Chronic Pain COVID-19/Coronavirus Depression Diabetes Gastrointestinal Disorders Inflammatory Bowel Disease (IBD) Lupus Multiple Sclerosis Nonalcoholic Steatohepatitis (NASH) Parkinson's Pediatrics and Adolescent Rare Diseases

Your privacy is important to us. Please confirm that you have reviewed our Privacy Policy and agree to the Terms of Use.

Yes, I have reviewed the privacy policy and agree to terms of use

Okay to receive text messages

Contact Us

Name

Email

Phone

Which Location?

Message

Brain Matters Research
(Delray Beach, FL & Stuart, FL)

Clinical Pharmacology of Miami
(Hialeah/Miami, FL)

Endeavor Clinical Trials
(San Antonio, TX)

Finger Lakes Clinical Research
(Rochester, NY)

HD Research
(Houston/Bellaire & Dallas/Carrollton, TX)

Midwest Clinical Research Center

Midwest Clinical Research
(Dayton, OH)

Neuropsychiatric Research Center of SW Florida

Neuropsychiatric Research Center
(Fort Myers, FL)

Pacific Research Network

Pacific Research Network
(San Diego, CA)

Richmond Behavioral Associates
(Staten Island, NY)

Woodland International Research Group

Woodland International Research Group
(Little Rock, AR)

Woodland Research Northwest

Woodland Research Northwest
(Rogers, AR)

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