Pneumococcal 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

Current 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

Language

Metro Area

Zip Code

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Metro Code

SiteID

State ID

CampRefID

Have you ever received a pneumonia (pneumococcal) vaccine?

Do you have any conditions that affect your immune system? (e.g., HIV, Hepatitis B/C, Leukemia, Lymphoma, Kidney disease, or an immune deficiency)

Have you ever been diagnosed with Guillain-Barré Syndrome (GBS)?

In the last 12 months, have you received any of these specific vaccines? (Shingrix, Fluad, Nuvaxovid, Arexvy, or Heplisav-B)

Eligibility Status