Screening

Please ensure you have read the Participant Information Sheet and then fill out your details in the sign up form below.

Participant Information Sheet

Pre-Screening Questions

Step 1 of 2

50%

CAPTCHA

Stage 1

Are you aged between 18 and 60 years?(Required)

Yes

Are you in good health?(Required)

Yes

Are you able to attend the study site at Addenbrooke's Hospital in Cambridge?(Required)

Yes

Have you read the participant information sheet?(Required)

Yes

Are you registered with a GP practice in the UK?(Required)

Yes

Are you already enrolled in another clinical trial?(Required)

Yes

Are you currently pregnant, breastfeeding or planning on becoming pregnant in the next 12 months?(Required)

Yes

Have you experienced a respiratory infection in the last 4 weeks?(Required)

Yes

Are you a current or recent regular smoker in the last 6 months with cigarettes, cigars or vapes?(Required)

Yes

Do you regularly drink more than 3 units a day (male) or 2 units a day (female) or regularly use recreational drugs?(Required)

Yes

Warning Message

Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored.

Information Message

Thank you for your interest, but unfortunately you need to be within travelling distance to the study site. Your data has not been stored.

Information Message

Unfortunately, we can't consider you for this trial until you have read the participant information leaflet provided at Lung Immune Challenge_PIS_V0.2_08.02.24. Please read the leaflet and then resume this questionnaire if you are still interested in participating in the trial.

Warning Message

Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored.

Confirmation Message

Thank you for your responses. You may be eligible to participate in this trial. Please proceed to the next section where we will ask for your consent to record more medical information.

Confirmation Message

Thank you for your interest in the trial. In order to help make the screening process efficient, we would like to gather information about your medical history here. This will be used to help decide if you are eligible to take part in the study. Giving your consent means that you are happy for us to store and use your personal information for the purposes of this trial. Information will be stored in accordance with the UK GDPR and Data Protection Act. Further information can be found at: University Of Cambridge Data Protection Statement.

I agree for the Study Team to record my personal information and information about my medical history. I agree to be contacted by the Study Team for the purposes of this trial.(Required)

Yes

Warning Message

Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored.

I understand and agree that the medical information I give here will be recorded, stored and used to assess eligibility(Required)

Yes

Warning Message

Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored.

I give permission for the study team to access my medical records either from the GP or NHS databases for the purposes of assessing eligibility.(Required)

Yes

Warning Message

Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored.

I'm happy for the study team to contact me by telephone and discuss my eligibility for the study, including my medical history. I understand that this information will be recorded and stored for the purposes of the study(Required)

Yes

Warning Message

Thank you for your interest. Unfortunately, you are not eligible to join this trial. Your data has not been stored.

Signature(Required)

What is your title?(Required)

(E.g. Mrs, Miss, Ms, Mr, Dr, Prof)

What is your full first name?(Required)

(as it appears on your passport)

What is your last name?(Required)

(as it appears on your passport)

What is your date of birth?(Required)

DD slash MM slash YYYY

What is your gender?(Required)

Male

Female

Non-binary

What is your email address?(Required)

What is your phone number?(Required)

Address

First Line of Address Post code

Do you have any medical conditions?(Required)

Yes

Please list all your medical conditions here:(Required)

Are you currently taking any medication?(Required)

Yes

Please list all your medications here:(Required)

Do you have any allergies to medication?(Required)

Yes

Please list medications you are allergic to here:(Required)

Are you currently taking part in any other research studies?(Required)

Yes

Please list all other research studies you are taking part in here:(Required)

How did you hear about the research study?

(e.g. Campus Newsletter)

If you have any further queries, you can send us an email here: cuh.lungchallenge@nhs.net