Unite Against Covid-19

Across the country, people are needed in the battle against COVID-19.

Adults aged 18 and older may be eligible to participate in local COVID-19 clinical trials that are enrolling now.

If you qualify you may:

See a physician or medical staff at no cost
Receive compensation for time and travel

Complete this short COVID-19 survey to see if you qualify

Please tell us about yourself so that we can find suitable study locations near you. All the information you complete will remain private.

First Name

Last Name

Primary Phone

Mobile Phone

Address

Apt. / Ste.

City

State

Zip Code

We need this information calculate your body mass index (BMI).

Height (Feet)

Height (Inches)

Weight (lbs)

Date of Birth

Gender

Male Female Other

Please choose the race and/or ethnicity that describes yourself. Choose all that apply:

Do you work in any of the following industries/occupations?

Retail Healthcare Food service (catering) Public/community official (for example, a police officer) Nursing home/long-term care facility Manufacturing or meat packing plant Transportation (for example, a taxi driver or bus driver) Other occupation that puts me at high risk of exposure to COVID-19 None of the above

Do you currently have COVID-19, or have you tested positive for COVID-19 in the past?

Yes No Not sure

Have you received/used any of the following?

Any vaccine (except an approved flu vaccine) within the past 30 days An experimental vaccine (including COVID-19 vaccine) within the past 6 months Blood transfusions within the past 3 months Cancer treatments (including chemotherapy, immunotherapy, and radiotherapy) within the past 6 months Experimental products indicated for the treatment or prevention of COVID-19 Immunosuppressant medication in the past 6 months (other than inhaled steroids, steroids as a cream, or taken by mouth for a short duration) Steroid medications (corticosteroids, a type of anti-inflammatory medication) by mouth or injection for more than 14 days within the past 6 months None of the above I'm not sure

Are you a smoker?

Yes No

If smoker, please tell us the brand of cigarettes and amount you smoke per day

Do you live in a nursing home or long-term care facility?

Yes No

Do you have a device with access to the internet (e.g. smartphone, computer, or tablet) that can be used to complete some study assessments electronically? This will not affect your eligibility for the study.

Yes No

Your privacy is important to us. Please confirm that you have reviewed our Privacy Policy and agree to the Terms of Use.

Yes, I have reviewed the privacy policy and agree to terms of use

Part of the ERG Network of Research Sites

Together we are one of the largest research organizations in the nation focusing on the conduct of clinical trials for healthy individuals and those suffering from psychiatric disorders, pain, Alzheimer’s, hepatic, renal and other debilitating diseases.

STUDIES ARE ENROLLING NOW!

MEMORY LOSS

For those who are struggling with memory loss, a memory screen is a step in the right direction to keeping their minds healthy. Apply for a FREE memory screen today!

COVID-19 Survey

Unite Against Covid-19

Across the country, people are needed in the battle against COVID-19.

Adults aged 18 and older may be eligible to participate in local COVID-19 clinical trials that are enrolling now.

If you qualify you may:

Complete this short COVID-19 survey to see if you qualify

Brain Matters Research

Brain Matters Research
(Kane Center)

STUDIES ARE ENROLLING NOW!

MEMORY LOSS

Unite Against Covid-19

Across the country, people are needed in the battle against COVID-19.

Adults aged 18 and older may be eligible to participate in local COVID-19 clinical trials that are enrolling now.

If you qualify you may:

Complete this short COVID-19 survey to see if you qualify

Brain Matters Research

Brain Matters Research (Kane Center)

STUDIES ARE ENROLLING NOW!

MEMORY LOSS

Brain Matters Research
(Kane Center)