Flu Prevention Study Prescreen

FLU PREVENTION STUDY PRE-SCREEN

Please submit the pre-screen form to be considered for participation in this trial.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How did you hear about us?*
Date of Birth *

MonthDayYear
Date
Height (ft & in)
Weight (lbs)
BMI
Have you been hospitalized or had any significant medical events in the last 2 months?*

YesNo
FEMALE: Are you of child bearing potential? (if NO, skip next question)

YesNo
FEMALE: Are you using any form of contraception? (birth control or preventive protection)

YesNo
Have you had a fever over 100.4°F within the last 7 days?*

YesNo
Have you received a seasonal flu vaccine in the last 14 days?*

YesNo
Have you had the FLU within the last 6 months?*

YesNo
Have you been in close contact with anyone with a confirmed FLU or COVID diagnosis within the last 7 days?*

YesNo
Have you had any major surgery within the last 4 weeks or planning a major surgery in the next 7 months?*

YesNo
Have you donated blood for any reason in the last 30 days that exceeds 450ml(1 Pint)?*

YesNo
Are you currently enrolled in any other study?*

YesNo
Screening A
Do you have any of the following conditions? (select all that apply)

chronic pulmonary disease (e.g., COPD, chronic bronchitis, cystic fibrosis, idiopathic pulmonary disease fibrosis)chronic persistent asthma requiring daily therapyhistory of cardiac disease (e.g., congestive heart failure, congential heart disease, coronary artery diseaseneurologic disorder (not including Alzheimer's or dementia) or had a previous strokeinsulin-dependent diabeteschronic kidney disorder (CKD) (Can NOT be receiving hemodialysis)chronic liver diseaseNone
Screening B
Do you have any of the following medical conditions? (select all that apply)

solid tumor cancer and receiving immunosuppressive treatmenthematologic malignancyreceived chimeric antigen receptor-modified T-cell therapyreceived B-cell depleting therapies(e.g., rituximab, ocrelizumab, ofatumumab, alemtuzumab) within the 12 months prior to screeningmoderate or severe primary or secondary immunodeficiencyadvanced or untreated human immunodeficiency virus (HIV) infection manifested by CD4 cell counts under 350/mm³ within 6 months of screeningis receiving immunosuppressive medicationsNone
Have you had any transplants?

solid organ transplant over 6 months and less than 2 yearsorgan, bone marrow, or stem cell transplantNone
Should be Empty:

FLU PREVENTION STUDY PRE-SCREEN

Screening A

Screening B