ELECTRONIC CONSENT: Please select your choice below. You may print a copy of this consent form for your records. Clicking on the "I consent" button indicates that
• You have read the above information
• You voluntarily agree to participate in the registry
* must provide value
I consent
Name (first and last name)
First name Last name
First name
* must provide value
Last name
* must provide value
Today M-D-Y This field will be used to distinguish between participants if necessary. It will not be stored in the final database for the registry.
What country do you live in?
United States (and territories) Canada (and territories) United Kingdom (UK) Ireland Australia New Zealand Other
Where do you live in the UK?
England Northern Ireland Scotland Wales
In which state do you currently reside?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (D.C.) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico U.S. Virgin Islands Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Other Saskatchewan Northwest Territories Nunavut Yukon Other
In which state or territory do you currently reside?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (D.C.) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico U.S. Virgin Islands Other
If other, please specify:
In which province or territory do you currently reside?
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Other
If other, please specify:
In which city do you currently reside?
Have you received any COVID-19 vaccine dose?
Yes
No
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
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
Date that you received (or will receive) the COVID-19 vaccine (Dose #1)
Today M-D-Y Skip if you have not received the vaccine yet.
Date that you received (or will receive) the COVID-19 vaccine (Dose #1)
Today M-D-Y Skip if you have not received the vaccine yet.
Manufacturer of the vaccine:
Pfizer
Moderna
Janssen
AstraZeneca
I don't know
Other
Pfizer
Moderna
Janssen
AstraZeneca
I don't know
Other
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
University of Washington - Montlake
Unversity of Washington - Northwest
University of Washington - Harborview
Seattle Children's Hospital
Valley Medical Center
Swedish Medical Center
Other
Unknown
If other, which location:
Please include Health Facility, City, State
Have you received a second dose of the vaccine yet?
Yes
No, but I am scheduled for the second dose
No
Only one dose is indicated for this specific COVID-19 vaccine
I don't know
Yes
No, but I am scheduled for the second dose
No
Only one dose is indicated for this specific COVID-19 vaccine
I don't know
Date that you received a second dose of the COVID-19 vaccine (Dose #2)
Today 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
University of Washington - Montlake
Unversity of Washington - Northwest
University of Washington - Harborview
Seattle Children's Hospital
Valley Medical Center
Swedish Medical Center
Other
Unknown
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
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:
What is your estimated delivery date?
Today M-D-Y
What date did you deliver your baby?
Today M-D-Y
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
University of Washington Medical Center - Montlake
University of Washington Medical Center - Northwest
Valley Medical Center
Swedish Medical Center
Other
Unknown
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
University of Washington Medical Center - Montlake
University of Washington Medical Center - Northwest
Valley Medical Center
Swedish Medical Center
Other
Unknown
If other, which location:
Do you agree to be contacted about potential quality improvement initiatives and/or research projects via text message?
Yes
No
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
No
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:
This email address will be stored in REDCaps and will not be collected as part of the survey response database. If you would like a copy of the consent form, we can send it to you via email.
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