Registration - Covaxin Clinical Trial

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Please read the READ ME section before registering.

Email *

READ ME

This is a form to show your interest in participating in the ICMR-Bharat Biotech Clinical trial. IMS and SUM Hospital is one of the approved trial sites in this study. This study gives you an opportunity to contribute to saving mankind by putting an end to the ongoing pandemic. By registering here, you will be giving the consent to be contacted in person through your phone number or e-mail id. Your registration does not give you the right to participate in the study. Participation will be on a first come first serve basis, and after screening for being a healthy human subject and meeting some inclusion and exclusion criteria. Phase 1 participants for registration should be between 18 and 55 years of age. Phase 2 participants for registration should be between 12 to 65 years. Please take 5 minutes to fill up the form carefully. These phases have concluded. You can now register to participate in Phase 3 trial, which will commence shortly

Name (in full) Surname first *

Gender *

Female

Male

Prefer not to say

Date of birth *

YYYY

Mobile number *

Alternate Mobile number

Occupation *

State of residence *

District of residence *

City/ Village of residence *

PIN Code of residence *

Current address (Flat/ Apartment or House no./Lane) *

Current address (Locality/ Nearest Landmark) *

Are you interested to participate in Covaxin clinical trial? *

Yes

Maybe

Interested in which phase of the Covaxin trial

Phase 1

Phase 2

No idea, please guide me

Phase 3 and higher

Are you interested in any other clinical trial? *

Yes

At PTCTU we have new vaccine trials through out the year. Are you interested in being a part of any of the below mentioned vaccine trials planned?

Japanese Encephalitis Vaccine (JEV) for Japanese

Td vaccine trial for Tetanus and Diphtheria

Meningococcal vaccine trial

Chikungunya Vaccine trial

Would you be interested to be contacted for or updated on any upcoming clinical trial? *

Yes

Thank you for contacting us. We normally take 24-48 hours to respond back. Kindly check your spam mail also for possible contacts through e-mail.

A copy of your responses will be emailed to the address you provided.

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