Long COVID Campaign - Candidate Form

Help raise awareness of Long COVID and the importance of COVID-19 vaccination.

Resolve to Save Lives (Resolve), a non-profit public health organization, is looking for Long COVID patients between the ages of 18-29 who want to share their stories! They are teaming up with state and local health departments to develop a media campaign to raise awareness of Long COVID and the importance of getting vaccinated, which will launch during Fall 2021.

Patients featured in the campaign will participate in a few brief preparatory calls and one day of filming within their preferred location – no travel will be required. They will be compensated $2,500 for their time.

If you are interested and think you would be a strong candidate to participate in the campaign, please fill out this survey and we will be in touch.

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* 1. Name

First

Last

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* 2. Contact information

Email address

Phone number

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* 3. Are you between the ages of 18 -29?

Yes

Please list your age:

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* 4. Are you fully vaccinated against COVID-19 (received the one-dose J&J vaccine or two doses of the Pfizer or Moderna vaccine)?

Yes

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* 5. Have you had a confirmed case of COVID-19 either via test or a physician’s assessment?

Yes

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* 6. Are you experiencing any of the following symptoms on a persistent basis, at least 12 weeks after being diagnosed with COVID-19 (check all that apply)

Fatigue

Shortness of breath

Chest pain

Joint pain

"Brain fog" - difficulty concentrating

Headache

Loss of taste or smell

Muscle pain

Dizziness

Trouble sleeping

Feelings of depression or anxiety

Symptoms that get worse after physical exertion

Gastrointestinal problems, including nausea, stomach aches, loss of appetite and diarrhea

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* 7. In which city and state do you live?

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* 8. What is your race/ethnicity? (select all that apply)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Long COVID Campaign - Candidate Form

Help raise awareness of Long COVID and the importance of COVID-19 vaccination.

Question Title

* 1. Name

Question Title

* 2. Contact information

Question Title

* 3. Are you between the ages of 18 -29?

Question Title

* 4. Are you fully vaccinated against COVID-19 (received the one-dose J&J vaccine or two doses of the Pfizer or Moderna vaccine)?

Question Title

* 5. Have you had a confirmed case of COVID-19 either via test or a physician’s assessment?

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* 6. Are you experiencing any of the following symptoms on a persistent basis, at least 12 weeks after being diagnosed with COVID-19 (check all that apply)

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* 7. In which city and state do you live?

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* 8. What is your race/ethnicity? (select all that apply)

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* 9. Please provide a brief summary of your experience with long COVID.