COVID-19 Pandemic Tracker Survey (US)
The purpose of this survey is to track and study the current pre-clinical progression of potential COVID-19 infections in the US population by location and related important factors. The collected data will be used to create a density map of infection 'hot zones' for first responders, medical professionals, and other researchers in anticipation of the increasing number of COVID-19 infections. These data will not be sold to third parties for any reason whatsoever.
Sign in to Google
to save your progress.
Disclaimer: By providing the information and data below (collectively “Data”), you consent to the use of this Data and its disclosure to researchers for the purpose of studying the COVID-19 Pandemic during a US National Emergency. You agree to indemnify, defend, and hold harmless any researcher involved with this study, which is being conducted in good faith. Your participation in this survey is voluntary. Completing the survey will involve your protected health information. You may decide by participating in the survey to submit such protected health information. Your participation constitutes authorization to use and make public such information under the federal HIPAA law and regulations and any applicable state or local privacy laws or regulations.
Yes, I Understand and Agree to this Disclaimer
Email Address (Optional, for Updates Only)
Unnumbered Street Address (e.g., Main St.)
City (e.g., Boston, Cambridge, Belmont, etc.)
Genetic and Health Data
Prefer Not to Say
Risk Factor and Comorbidity Assessment: Please Indicate any and all of the following pre-existing conditions that you have, whether treated or not:
Diabetes Type I or II
High Blood Pressure (e.g., Hypertension)
Cancer (of any type)
Immunodeficiency (e.g., HIV/AIDs, organ transplant recipient)
Autoimmune Disease (e.g., Rheumatoid Arthritis, Lupus)
Crohn's Disease or Ulcerative colitis
Blood Disease (e.g., Anemia, platelet or white blood cell abnormalities)
Medications: Please indicate any and all of the following medications you have taken recently
NSAIDs (e.g., Ibuprofen, Naproxen, etc.)
Oral or Injected Steroids (e.g., Prednisone, Methylprednisone, etc.)
Immune Suppression Medications or Biologic Therapies (e.g., Rituximab, Infliximab, etc.)
Chemotherapy (of any type)
Current Symptoms Data
Current COVID-19 Infection Status
Have you been hospitalized?
Your current influenza (flu) infection status
Were you vaccinated for the flu this year?
If ill, what are your current flu-like symptoms?
Fever of 100.4 F or higher
Difficulty Breathing/Shortness of Breath
Elevated Heart Rate (>100 BPM)
Gastrointestinal changes (e.g., diarrhea)
Other (not specified above)
How long have you had these symptoms?
> 4 weeks
Potential for Exposure Data
Are you a First Responder (e.g., MD, PA, RN, EMT, etc.)?
Yes, and I am currently treating COVID-19 patients
Yes, but I am not currently treating COVID-19 patients
Have you had close and unprotected contact with someone who has tested positive for COVID-19?
Unknown (Possibly, Yes)
Unknown (Not to my knowledge, No)
How many individuals in your close network (e.g., family and close friends) are ill with flu-like symptoms?
What is the current degree of your self-isolation or elective/mandated quarantine?
I do not leave my location at all (i.e., elective/mandated quarantine)
I leave my location rarely (e.g., mail retrieval, emergencies)
I leave my location infrequently (e.g., essential work and errands, mental health relief)
I leave my location moderately (e.g., non-essential work, all errands, safe outdoor exercise, walks)
I leave my location often (e.g., any work, recreation, small social events, etc.)
I leave my location freely and as needed
How many hours daily do you spend outside of your home?
Thoughts and Concerns
Never submit passwords through Google Forms.
This form was created inside of Google Apps for Harvard.