Pediatric Covid-19 Questionnaire

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

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Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

State ID

CampRefID

Race

Ethnicity

Is your child between 12 and 17 years old?

Does your child have a body weight of at least 88lbs?

Has your child had COVID-19 in the last 4 months?

Has your child ever received COVID-19 antibodies (such as monoclonal antibodies or convalescent plasma)?*

Eligibility Status