This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range.

The value you provided is outside the suggested range.

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^[a-z0-9-]{3}$/i

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^[a-z]{3}$/i

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3])(:[0-5][0-9]){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[U,H,N,Z]+\d{7}$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

iQhE5hkuGD7dQhrhyBxPt7vcgkt8F2vqWhX7JztzBUbLgRgSYVuU8YBKcyakbPrSNct5TYYTdcmNDpchNXve7winYVxXtfvXnSodhrhhSCHR3fGfYAHgIS2

COVID-19 Vaccine in Pregnancy and Lactation: Registry to Explore Immunization Practices, Outcomes and Quality Improvement Initiatives

Returning?

Please complete the survey below for the COVID-19 Vaccine in Pregnancy and Lactation registry.

Thank you!

You are invited to participate in an online registry of persons who receive the COVID-19 vaccine and who are also pregnant, postpartum, lactating and/or contemplating pregnancy.

This is a registry that has been developed by Dr. Alisa Kachikis and other investigators in the University of Washington Department of Obstetrics and Gynecology. It should take approximately 3 minutes to register your information.

KEY INFORMATION:
• Participating in this registry is entirely voluntary.
• The purpose of this registry is establish a listserv of persons who receive the COVID-19 vaccine who are also pregnant, postpartum, lactating or contemplating pregnancy in the next 1-2 years in order to potentially involve participants in quality improvement initiatives and/or research studies.
• It should take about 3 minutes to sign up for this registry.
• Your contact information will be kept confidential and will only be used for the purposes of informing you of quality improvement initiatives and/or research studies on COVID-19 vaccine in pregnancy and lactation that you may be eligible for.

PARTICIPATION
Your participation in this registry is voluntary. You are free to decline to answer any particular question you do not wish to answer for any reason. You may be contacted about quality improvement initiatives and/or research projects but may refuse to take part in any of these activities.

BENEFITS
You will receive no direct benefits from participating in this registry. However, you may be eligible to participate in quality improvement and research projects which may improve our knowledge of COVID-19 vaccine in pregnancy and lactation in the future.

RISKS
There is risk that you may find some of the questions to be sensitive or to be uncomfortable to answer. You may skip over these questions if you like.

CONFIDENTIALITY
Your registration in this listserv will be entered into a REDCap database, where data will be stored in a password protected electronic format. REDCap uses a MySQL database via a secure web interface to ensure HIPAA compliance and confidentiality and is housed on secure servers operated by the Institute of Translational Health Sciences at the University of Washington.

At the end of the registration process you will be asked if you agree to be contacted for potential future quality improvement initiatives or research projects via text message and/or email.

CONTACT
If you have questions at any time about the study or the procedures, you may contact Dr. Alisa Kachikis via email at COVIDVACCPREG@uw.edu.

If you have any questions, concerns, or complaints that you wish to address to someone other than the investigator, you may contact the University of Washington Human Subjects Division at hsdinfo@uw.edu or by calling (206)-543-0098 or by calling collect at (206) 221-5940.

Please fill out the information below.

M-D-Y

Add signature

Yes

No, but I am scheduled for my first dose

No, but I plan to get the vaccine.

No, I do not plan on getting the vaccine.

Other

reset

M-D-Y

Pfizer

Moderna

Janssen

AstraZeneca

I don't know

Other

reset

University of Washington - Montlake

Unversity of Washington - Northwest

University of Washington - Harborview

Seattle Children's Hospital

Valley Medical Center

Swedish Medical Center

Other

Unknown

reset

Yes

No, but I am scheduled for the second dose

Only one dose is indicated for this specific COVID-19 vaccine

I don't know

reset

M-D-Y

University of Washington - Montlake

Unversity of Washington - Northwest

University of Washington - Harborview

Seattle Children's Hospital

Valley Medical Center

Swedish Medical Center

Other

Unknown

reset

Pregnant

Not pregnant, but breastfeeding

Not pregnant, but either currently trying to get pregnant or attempting pregnancy in the next 1-2 years.

Other

Expand

M-D-Y

University of Washington Medical Center - Montlake

University of Washington Medical Center - Northwest

Valley Medical Center

Swedish Medical Center

Other

Unknown

reset

University of Washington Medical Center - Montlake

University of Washington Medical Center - Northwest

Valley Medical Center

Swedish Medical Center

Other

Unknown

reset

We are conducting some research studies including a large longitudinal outcomes study on COVID-19 vaccine in pregnancy, lactation or in persons planning pregnancy in the near future. This is especially important since there is currently no data on COVID-19 vaccine in pregnancy or lactation.

We would like to send you more information about this (or other studies) as applicable.

Email is the EASIEST way to send you further information, but we can also text you a link. Please see questions below:

Yes

reset

Yes

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.