Pre-Screening Questionnaire
Michigan Center of Medical Research - Varicella Virus Vaccine
If you are completing this questionnaire on behalf of your child please first confirm your own age. (This question refers to the person answering this questionnaire. You must be 18 years of age or older to complete the questionnaire).
*
I am 18 years of age or older.
I am less than 18 years of age.
Please select your child's age below. (We need this information because some studies are only suitable for children above or below a certain age).
Less than 9 months of age.
9-11 months of age.
12-15 months of age.
16 months or older.
Has your child ever had a chickenpox infection or received a chickenpox vaccine? Chickenpox (varicella virus infection) is a contagious disease that causes an itchy rash and red spots or blisters all over the body.
No.
Yes.
I don't know.
Is your child currently taking part in any clinical research study in which they receive an investigational medicine?
No.
I don't know.
My child participates in a clinical research study and receives an investigational medication.
My child participates in a clinical research study but does not receive an investigational medication.
Please choose the race and/or ethnicity that describes your child. Choose all that apply. (We need this in information to make sure that we are reaching people of different backgrounds. Diversity in clinical research helps ensure that vaccines and medications are generally safe and work for different types of people).
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.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What is your preferred method of contact?
Email.
Phone.
What times are you most available for us to contact you?
Please Select
Mornings
Afternoons
Evenings
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Thank you for taking the time to complete this questionnaire! A member of our study team will be in contact with you soon. Please comment below if you have additional questions, comments, or concerns for us regarding this study.
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