C104 Marburg Volunteer Interest Survey

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Study Participation:

This study requires participants to attend 9 in-clinic visits over 7 months. To participate in this study, you will receive a vaccine. Those who are eligible and attend the in-clinic visits will receive $75.00 per visit to compensate for time and travel.

Key Facts about the Marburg Virus:

Marburg Virus Disease occurs in sporadic outbreaks primarily in Sub-Saharan Africa.
Currently, there are no approved vaccines or treatments for the disease.

Please complete the survey below to express your interest in participating in IAVI's Protocol C104 "A Phase 1 Randomized, Observer-blind, Placebo-controlled, Dose-escalation Clinical Trial to Evaluate the Safety and Immunogenicity of the rVSVΔG-MARB-GP Vaccine in Adults in Good General Health".

Thank you!

First Name

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Last Name

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Email Address

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Phone Number

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Date of Birth (mm/dd/yyyy)

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M-D-Y

Age

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Do you live in the Washington, DC metropolitan area?

In-person clinic visits will be conducted at the GW Medical Faculty Associates in Foggy Bottom, Washington, DC.

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Yes

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Sex

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Male

Female

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Are you pregnant or breastfeeding?

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Yes

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What is your approximate height in inches?

What is your approximate weight in pounds?

BMI (hidden in survey)

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Have you tested positive HIV?

Yes

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Do you have a current or active Hepatitis B or Hepatitis C infection?

Yes

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Race

Asian

American Indian or Alaska Native

Black or African American

Native Hawaiian or Other Pacific Islander

White

Multiracial

Other

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Multiracial, please specify:

Other, please specify:

Ethnicity

Hispanic or Latino

Non-Hispanic

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How did you hear about this study?

Please check all that apply.

Clinical Connection

ClinicalTrials.gov

Craigslist

Doctor Referral

Facebook

Flyer

GW Docs (MFA Website)

GW VRU Website

GW VRU Registry Email

Internet ad

Research Match

Word of Mouth

Other

Other, please specify:

May we contact you about opportunities to participate in other clinical trials?

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Yes

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Please download and review the attached Informed Consent Form for more information about the study and click "Submit" to complete the survey.

Attachment:C104_Diemert Main ICF Pro00092662 Mar2326.pdf

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