VAC089 Trial: Blood Stage Malaria Vaccine

1.1. What is your name? Required

2.2. What is your email address? Required

3.3. What is your mobile telephone number? We will use this information to contact you by telephone or email to arrange a screening visit. Required

4.4. What is the first part of your post code? Required

5.5. What is your date of birth? Required

Dates need to be in the format 'DD/MM/YYYY', for example 27/03/1980.

(dd/mm/yyyy)

6.6. Are you registered with a GP Practice in the UK? Required

Yes

No

a.6.a. What is the name and address of your GP surgery?

7.7. Are you aware of the specific requirements relating to contraception for this trial? Required

Yes

No

8.8. Are you currently taking any medication? Required

Yes

No

a.8.a. Please give details of any medication you are currently taking:

9.9. Are you currently under the care of, or waiting for an appointment with, a hospital specialist? Required

Yes

No

a.9.a. Please give details of any specialist care or appointments.

10.10. Have you ever had a cancer diagnosis? Required

Yes

No

a.10.a. If yes, please give details

11.11. Have you previously taken part in a clinical trial involving a vaccine? Required

Yes

No

a.11.a. Please give details of any trials you have previously participated in that have involved a vaccine (if possible: the disease studied, vaccine given, who the study was with).

12.12. Have you ever had malaria?

Yes

No

a.12.a. If yes, please give details.

13.13. Have you travelled to any Malaria-endemic areas in the past 6 months e.g. Africa, Asia?

Yes

No

a.13.a. If yes, please give details of where/when you travelled.

14.14. Do you have any plans to travel in the next 12 months? Required

Yes

No

a.14.a. If yes, please give approximate dates and locations, if possible.

15.15. How did you hear about us? Required

a.15.a. If you selected Other, please specify:

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