RECOVER COVID 19 Study -Interest to Participate
Healthcare & First Responders

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* 1. What is your first and last name?

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* 2. What is your email address?

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* 3. What is your phone number?

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* 4. What field do you work in?

Healthcare (Physician or MD, Physician Assistant, Nurse Practitioner)

Fire

Police

EMT

Nurse

Dentist or Dental Assistant

Support Staff (assistants, administrative, technician, pharmacist, social work, dietician, phlebotomist, physical therapy, occupational therapy, speech therapy, radiologist, phycologist, respiratory therapist, cleaning, facilities)

Other (please specify)

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* 5. Are you a University of Utah employee?

Yes

Other (please specify)

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* 6. What is your age range?

Under 18

18-39

40+

Other (please specify)

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* 7. What is your gender?

Male

Female

Other

Other (please specify)

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* 8. Do you work full time (or at least 20 hours a week)?

Yes

Occasionally

Other (please specify)

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* 9. Do you plan on relocating out of State within the next 12 months?

Yes

Temporarily

Other (please specify)

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* 10. Have you received the COVID-19 Vaccine?

Yes

I'm scheduled to be vaccinated (please specify the date)

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* 11. You receive up to $50 compensation for referrals. Please send us names of those you think maybe interested:

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* 12. Thank you so much for your interest in our RECOVER Study. Any questions can be directed to RECOVER@utah.edu. If you are eligible, you will be contacted shortly about enrolling in the study. Thank you so much for your time and support!

RECOVER COVID 19 Study -Interest to Participate Healthcare & First Responders

Question Title

* 1. What is your first and last name?

Question Title

* 2. What is your email address?

Question Title

* 3. What is your phone number?

Question Title

* 4. What field do you work in?

Question Title

* 5. Are you a University of Utah employee?

Question Title

* 6. What is your age range?

Question Title

* 7. What is your gender?

Question Title

* 8. Do you work full time (or at least 20 hours a week)?

Question Title

* 9. Do you plan on relocating out of State within the next 12 months?

Question Title

* 10. Have you received the COVID-19 Vaccine?

Question Title

* 11. You receive up to $50 compensation for referrals. Please send us names of those you think maybe interested:

Question Title

* 12. Thank you so much for your interest in our RECOVER Study. Any questions can be directed to RECOVER@utah.edu. If you are eligible, you will be contacted shortly about enrolling in the study. Thank you so much for your time and support!

RECOVER COVID 19 Study -Interest to Participate
Healthcare & First Responders