C109 Sudan Ebolavirus Volunteer Interest Survey

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K3pfXp2oA8XRNQnTsGU3I52A7qCdtCSunN3FpzHNQVI7fmm9fexaAMgg7FzT2AWKo46N9oiiBEpebFf5BaP6LqcSBnQWg95McC66cru2yPSfDxT6t57gru3oQ

Study Participation:

This study requires participants to attend 9 in-clinic visits over 7 months. If you participate in this study, you will receive an investigational vaccine or placebo. The placebo used in this study looks exactly like the investigational vaccine, but it does not contain any active investigational 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 Sudan Ebolavirus:

It is spread through direct contact with an infected person.
The Sudan Ebolavirus occurs in sporadic outbreaks primarily in Sub-Saharan Africa.

Please complete the survey below to express your interest in participating in IAVI's Protocol C109 "A Phase 1, Randomized, Observer-blind, Placebo-controlled, Dose-escalation Clinical Trial to Evaluate the Safety and Immunogenicity of rVSV∆G-SUDV-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?

Yes

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What is your approximate height in inches?

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What is your approximate weight in pounds?

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BMI (hidden in survey)

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Have you tested positive for HIV?

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Yes

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

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Yes

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Race

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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:

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Other, please specify:

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Ethnicity

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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

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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:Diemert Main ICF May0626.pdf

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