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JjdQbhPuqf3FV3oDX5HzmKV8TY4JoSd8TQCYQg7kxGLUSwanyGor27NE

COVID-19 Prevention Network (CoVPN) Screening Registry

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Title	COVID-19 Prevention Network (CoVPN) Screening
Weill Cornell Medicine IRB #	20-07022340
Principal Investigator	Marks, Kristen

You are invited to enroll in our COVID-19 Prevention Network (CoVPN) Screening Registry.

About the Registry

The purpose of this study is to create a registry of volunteers interested in participating in COVID-19 vaccine research. This registry will only be used by researchers at Weill Cornell Medicine (WCM) to identify persons that could be eligible to participate in what we hope will be multiple clinical trials of various COVID-19 vaccines. By entering the registry, you may be able help us understand if certain vaccines can prevent infections with the virus that causes COVID-19.

We anticipate a tremendous amount of interest so we cannot promise to contact all who are interested. We ask that you please complete only one questionnaire per person.

Please understand that your participation in this screening registry is entirely voluntary and you can elect to withdraw from the registry at any time. You may not benefit from participating in this registry. This registry will remain open until the study team has finished recruiting volunteers into the last COVID-19 prevention study which potentially may occur several years from now.

You may be withdrawn from the registry by study staff you enroll in a COVID-19 prevention study, if you do not meet criteria for any of the related studies, or for administrative reasons. This can occur without your consent.

Confidentiality, Data Storage and Use

Efforts will be made to protect your personal information to the extent allowed by law. However, we cannot guarantee absolute confidentiality. Records of registry participants will be stored and kept according to legal requirements. Organizations that are involved in the CoVPN studies may request to inspect and/or copy your registry data for quality assurance. These organizations include groups such as:

o Researchers at Weill Cornell Medicine (WCM)
o The WCM Institutional Review Board (IRB)
o The COVID-19 Prevention Network (CoVPN) and/or their representatives
o The Office of Human Research Protection (OHRP)
o Department of Health and Human Services
o National Institutes of Health
o The Food and Drug Administration (FDA) and/or their representatives

By submitting this questionnaire, you authorize access to this confidential information. Your information will be stored securely on our servers and will only be available to researchers working on CoVPN studies at WCM and protected by layers of authentication. Any information you provide will NOT be used for any purposes other than those described above.

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Yes

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STOP!
We are sorry, but we are only seeking volunteers ages 18 and older. Please do not submit a questionnaire.

¡PARE!
Lo sentimos pero buscamos a voluntarios que tienes 18 años o mas de edad. Por favor no complete este cuestionario.

Yes

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STOP!
We are sorry, but we are only seeking volunteers without a history of suspected or confirmed SARS-CoV-2 infection. Please do not submit a questionnaire.

¡PARE!
Lo sentimos pero buscamos a voluntarios sin historia de infección con SARS-CoV-2 confirmada or sospechada. Por favor no complete este cuestionario.

M-D-Y

Yes

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Morning

Afternoon

Evening

Weill Cornell Infectious Diseases and Travel Medicine Clinic
Weill Greenberg Center, 4th Floor
1305 York Ave (Upper East Side)
New York, NY 10065

Cornell Clinical Trials Unit
53 W 23rd St, Floor 6 (Chelsea)
New York, NY 10010

I cannot attend visits at these locations

STOP!
Unfortunately, we don't have other clinic sites. Please do not submit a questionnaire. To potentially volunteer for a COVID-19 vaccine study at another site visit: www.coronaviruspreventionnetwork.org.

¡PARE!
Lamentamos pero no tenemos otros sitios. Por favor no complete este cuestionario. Para enlistarse en un ensayo de una vacuna contra el COVID-19 en otro sitio enlacese Ud. a: www.coronaviruspreventionnetwork.org.

Female

Male

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Female

Male

Transgender Female

Transgender Male

Other (enter below)

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White

Black

Asian

Pacific Islander/Hawaiian

Native American/Native Alaskan

Other

Prefer not to disclose

Yes

Prefer not to disclose

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Yes

Not sure

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Expand

Yes

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Yes

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Older than 65 years of age

Medical condition: chronic lung disease, heart disease (heart failure, coronary artery disease, etc.), severe obesity, diabetes, or liver disease

Work in healthcare (healthcare worker, medical transport/EMT, lab personnel, logistics)

Work in overcrowded spaces, frequent contact with others, or exposed to general public (schools, public transit, essential retail, police, other essential workers, etc)

Frequently use public transit (at least 5 times per week)

5 or more persons live in your home or dwelling unit

Whom Do I Call if I Have Questions or Problems?

For questions about the registry or for assistance with this questionnaire contact the registry study team at:
1-855-416-4155
cctucovid@med.cornell.edu

If you have questions about your rights as a research participant in this registry, contact the WCM IRB Office. Direct your questions to:

Institutional Review Board at:
(646) 962-8200
Email: IRB@med.cornell.edu
1300 York Avenue
Box 89
New York, New York 10065

Authorization

By completing and submitting this questionnaire, you are granting permission to Dr. Kristen Marks and the study team to securely store and use this information as described above. You can revoke this permission at any time by contacting cctucovid@med.cornell.edu or calling 212-746-7204.

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