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.
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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. *
Required
Email Address (Optional, for Updates Only)
Location Data
Unnumbered Street Address (e.g., Main St.) *
City (e.g., Boston, Cambridge, Belmont, etc.) *
State *
Zip Code *
Genetic and Health Data
Age *
Gender *
Blood Type *
Risk Factor and Comorbidity Assessment: Please Indicate any and all of the following pre-existing conditions that you have, whether treated or not: *
Required
Medications: Please indicate any and all of the following medications you have taken recently
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? *
Required
How long have you had these symptoms? *
Potential for Exposure Data
Are you a First Responder (e.g., MD, PA, RN, EMT, etc.)? *
Have you had close and unprotected contact with someone who has tested positive for COVID-19? *
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? *
Required
How many hours daily do you spend outside of your home? *
Thoughts and Concerns
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