COVID-19 Vaccination Clinical Trials

Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code *

What sex were you assigned at birth? *

Male

Female

Prefer not to say

How would you rate your overall health? *

Excellent

Very Good

Good

Fair

Poor

Have you ever tested positive for COVID-19? *

Yes - tested positive for COVID-19

No

When was the last time you tested positive for COVID-19? *

0 - 1 months ago

1 - 2 months ago

2 - 3 months ago

More than 3 months ago

Have you ever been vaccinated for COVID-19? *

Yes - vaccinated for COVID-19

No

Note: These are studies for a publicly available, licensed, non mRNA vaccine.

When did you receive your most recent COVID-19 vaccine shot? *

0 - 1 months ago

1 - 2 months ago

2 - 3 months ago

More than 3 months ago

Have you been diagnosed (by a doctor) with any medical conditions? *
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

Examples include: depression, type 1 diabetes or type 2 diabetes, chronic obstructive pulmonary disease (COPD), interstitial lung disease, bronchiectasis, down syndrome, heart failure, cardiomyopathy, human immunodeficiency virus (HIV), dysthymia, cystic fibrosis, bipolar disorder, cyclothymic disorder, schizophrenia, dementia, Parkinson’s disease, tuberculosis, cirrhosis, non-alcoholic fatty liver disease, autoimmune hepatitis

Are you taking any medications or treatments for your health conditions? *
Please list them below or type ‘none’.

Examples include: dialysis

Do you currently smoke cigarettes? *

Yes - currently smoke

No - but smoked in the past

No - never smoked

Note: This also includes e-cigarettes or vaping devices.

Please, enter your height below. *

How much do you weigh in Lbs (pounds)? *

Are you currently participating in another Clinical Trial? *

No

Yes - participating in another clinical trial

Are you currently pregnant, breastfeeding, or planning to become pregnant? *

Yes - pregnant/ breastfeeding/ or planning to become pregnant

No

Which racial or ethnic group(s) do you identify with? *
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
Please select all that apply.

What is the best day/time to reach you via telephone (we know you are busy)? *

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

Yes No

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

COVID-19 Vaccination Clinical Trials

Study benefits include:

You may qualify if you: