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

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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.

Name (first and last name)

First name

* must provide value

Last name

* must provide value

Date of birth

M-D-Y

* must provide value

Add signature

What country do you live in?

If other, which country?

Where do you live in the UK?

In which state do you currently reside?

In which state or territory do you currently reside?

If other, please specify:

In which province or territory do you currently reside?

If other, please specify:

If other, which state?

In which city do you currently reside?

Have you received any COVID-19 vaccine dose?

Yes

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How many doses of a COVID-19 vaccine have you received?

Have you received the first dose of the COVID-19 vaccine?

* must provide value

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

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If other, explain:

Date that you received (or will receive) the COVID-19 vaccine (Dose #1)

M-D-Y

Date that you received (or will receive) the COVID-19 vaccine (Dose #1)

M-D-Y

Manufacturer of the vaccine:

Pfizer

Moderna

Janssen

AstraZeneca

I don't know

Other

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If other pharmaceutical company, which one:

Where did you receive your 1st dose of COVID-19 vaccine (which hospital, pharmacy, etc)?

Where did you receive your 1st dose of the COVID-19 vaccine?

University of Washington - Montlake

Unversity of Washington - Northwest

University of Washington - Harborview

Seattle Children's Hospital

Valley Medical Center

Swedish Medical Center

Other

Unknown

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If other, which location:

Have you received a second dose of the vaccine yet?

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

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Date that you received a second dose of the COVID-19 vaccine (Dose #2)

M-D-Y

Where did (or will) you receive your 2nd dose of COVID-19 vaccine (which hospital, pharmacy, etc)?

Where did you receive the COVID-19 vaccine (dose #2)?

University of Washington - Montlake

Unversity of Washington - Northwest

University of Washington - Harborview

Seattle Children's Hospital

Valley Medical Center

Swedish Medical Center

Other

Unknown

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Are you currently:

* must provide value

Pregnant

Not pregnant, but breastfeeding

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

Other

If other, please add information:

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What is your estimated delivery date?

M-D-Y

What date did you deliver your baby?

M-D-Y

Who is your OB provider?

Where are you planning on delivering your baby?

University of Washington Medical Center - Montlake

University of Washington Medical Center - Northwest

Valley Medical Center

Swedish Medical Center

Other

Unknown

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Where are you planning on delivering your baby (i.e. name of hospital, medical center, birth center, home birth, etc)?

Where are you planning on delivering your baby?

University of Washington Medical Center - Montlake

University of Washington Medical Center - Northwest

Valley Medical Center

Swedish Medical Center

Other

Unknown

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If other, which location:

Do you agree to be contacted about potential quality improvement initiatives and/or research projects via text message?

Yes

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What is the best phone number to reach you via text?

Do you agree to be contacted about potential quality improvement initiatives and/or research projects via email?

Yes

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Please enter email address so that we can contact you via email (if you agreed above) or send you a copy of the consent form:

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