Study Visit CRF - Study #07A-CLI-001 - Site #01
Instructions: To be completed by research staff upon subject enrollment, after subject has signed the Informed Consent Form.
Subject Number
*
Date of Visit
*
Date Format: MM slash DD slash YYYY
Informed Consent/HIPAA Authorization
Informed Consent Date
*
Date Format: MM slash DD slash YYYY
Would like to be contacted for future research?
*
Yes
No
Inclusion/Exclusion Criteria
Inclusion
*
The subject must be 18 years of age or older
Yes
No
Symptomatic or Asymptomatic COVID-19 Subjects
*
Symptomatic
Asymptomatic
Symptomatic Subjects must be currently experiencing:
- Fever (100 Degrees and Above) - Plus one additional symptom (cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea and/or sore throat)
Yes
No
N/A
Exclusion
*
Subject is currently suffering from nasal trauma such as a nosebleed
Yes
No
Inclusion & Exclusion criteria have been met?
*
Yes
No
Demographics
Gender
*
Select Gender
Male
Female
Not Specified
Age
*
Select Age
18 - 29 Years Old
30 - 39 Years Old
40 - 49 Years Old
50 - 59 Years Old
60 - 69 Years Old
70+ Years Old
Ethnicity
*
Select Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other
Unknown
Specify Ethnicity
Specimen Collection
Specimen collection date
*
Date Format: MM slash DD slash YYYY
Collection Time
*
:
HH
MM
AM
PM
Collection Type
*
Single Nasal Collection
Double Nasal Collection
Swab Type
*
MTS
Nasal
Specify Swab Type
From which nostril was Specimen collected?
*
Right
Left
Both
Nostril #1 - To Stopper?
*
Yes
No
Nostril #1 - Turned 3X?
*
Yes
No
Other
# of Turn for Nostril #1
Nostril #2 - To Stopper?
Yes
No
Nostril #2 - Turned 3X?
Yes
No
Other
# of Times for Nostril #2
Detail any additional study-specific notes regarding the subject or subject visit
Signature Date
*
Date Format: MM slash DD slash YYYY
Signature of Person Completing Form
*
