Registration - Covaxin Clinical Trial
Please read the READ ME section before registering.
Email address *
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.
Name (in full) Surname first *
Gender *
Date of birth *
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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? *
Interested in which phase of the Covaxin trial
Are you interested in any other clinical trial? *
Which other clinical trial are you interested in?
Would you be interested to be contacted for or updated on any upcoming clinical trial? *
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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