Choose your preferred language to proceed (this questionnaire is only available in English or Spanish)
Idioma preferido (este cuestionario está disponible sólo en Inglés o Español)
* must provide value
EnglishInglés
SpanishEspañol
EnglishInglés
SpanishEspañol
Email, must be unique to you* must provide value
Are you 18 years of age or older?* must provide value
Yes
No
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.
Have you been diagnosed with SARS-CoV-2 (COVID-19) infection by either antibody test (serology) or viral swab?* must provide value
Yes
No
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.
First Name* must provide value
Last Name* must provide value
Date of Birth* must provide value
M-D-Y month-day-year
Preferred contact phone number* must provide value
Can we leave a voice message?* must provide value
Yes
No
Best time to contact* must provide value
Morning
Afternoon
Evening
Check all the apply
Zip Code* must provide value
The borough in which you live
Bronx Brooklyn Manhattan Queens Staten Island Do not live in NYC
Optional. Opcional.
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Where would you prefer to attend study visits?* must provide value
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
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
Check all that apply
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 .
Your sex at birth* must provide value
Female
Male
Gender identify that best fits you* must provide value
Female
Male
Transgender Female
Transgender Male
Other (enter below)
Female
Male
Transgender Female
Transgender Male
Other (enter below)
Your gender identity
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Which best describes your race?* must provide value
White
Black
Asian
Pacific Islander/Hawaiian
Native American/Native Alaskan
Other
Prefer not to disclose
White
Black
Asian
Pacific Islander/Hawaiian
Native American/Native Alaskan
Other
Prefer not to disclose
Check all that apply
Are you Hispanic/Latino(a)?* must provide value
Yes
No
Prefer not to disclose
Yes
No
Prefer not to disclose
Are you currently participating in a clinical trial?* must provide value
Yes
No
Not sure
What kind of study or studies are you participating in? Provide name(s) of study or studies, if possible, and describe.
Have you participated in or are currently participating in a SARS-CoV-2 prevention or treatment study?* must provide value
Yes
No
Have you been hospitalized in the last 90 days?* must provide value
Yes
No
Click all that apply to you 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
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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