Pre-Study Health Check

• Email*
  The health and safety of our focus group participants are of the utmost importance. Please take a moment to answer these brief questions to verify your personal health and the safety of everyone involved. First, please enter the email address we have on file for you.
• Q1*
  In the past 5 days, have you experienced any unexplained persistent dry cough? Yes or no?
  • Yes
  • No
• Q2*
  In the past 5 days, have you experienced any unexplained fever? Yes or no?
  • Yes
  • No
• Q3*
  In the past 5 days, have you experienced any unexplained difficulty breathing or shortness of breath? Yes or no?
  • Yes
  • No
• Q4*
  In the past 5 days, have you experienced any unexplained new loss of taste or smell? Yes or no?
  • Yes
  • No
• Q5*
  In the past 5 days, have you experienced any unexplained muscle pain? Yes or no?
  • Yes
  • No
• Q6*
  In the past 5 days, have you experienced any unexplained chills? Yes or no?
  • Yes
  • No
• Q7*
  In the past 5 days, have you experienced any unexplained sore throat? Yes or no?
  • Yes
  • No
• Q8*
  In the past 5 days, have you experienced any unexplained headache? Yes or no?
  • Yes
  • No
• Q9*
  Do you live with someone in the same household, have a spouse/intimate partner, or have you been providing care to someone currently being tested, treated, or diagnosed with COVID-19?
  • Yes
  • No
• Q10*
  Have you been in close contact [meaning spent 10 minutes or more] with any person who has been diagnosed with COVID-19, or have you been notified of any COVID-19 exposure to yourself in the past 5 days?
  • Yes
  • No
• Q11*
  While not required to participate in this study, we track vaccination status for future studies to ensure we are following local policy. Have you received any COVID-19 vaccinations? Either the first [partially vaccinated], or second dose [fully vaccinated]?
  • Yes; I am fully vaccinated (have my first and second dose)
  • Yes; I am partially vaccinated (have my first dose)
  • No; I have not received a COVID-19 vaccination

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