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Expression of Interest - The Activation Study
We look forward to welcoming you to The Activation Study! We just need a few details to register to your interest. This form takes around 3–5 minutes to complete. Your information will remain confidential and is used only to assess your eligibility for current or future research studies.
Contact Details
First Name
Last Name
Email
Mobile
Vaccination Status
Have you had the following vaccines in the last 4 years?
(Tick all that apply)
Meningitis (types A, C, Y, W-135, Brands - Nimenrix®, Menactra®, Menveo®, MenQuadfi®)
Meningitis B (Bexsero® or Trumenba®)
Streptococcus pneumoniae: Pneumovax 23 or Prevenar 13/20 (E.g Vaccines that protect against Pneumonia, Ear infections, Sinus Infections and Meningitis)
Haemophilus influenzae type b (Hib): Hiberix or equivalent (Bacterial infections caused by influenza)
COVID-19: Completion of a primary vaccination series
I’m not sure
No
Do you have the documentation for your vaccination?
Yes
No
If you haven’t had these vaccines, are you willing to get vaccinated before starting the study medication?
Health Background
Are you a smoker?
How many cigarettes or equivalent nicotine containing products do you smoke?
Less than 5 per week
Less than 5 per day
Between 5 and 10 per day
More than 10 per day
Do you have a history of anaphylaxis or do you have any severe allergies to food or medication?
We define an allergy as severe if symptoms include mouth/throat/face swelling, shortness of breath or a whole-body rash, or if it required hospitalisation
Do you have a history of any other medical or mental health conditions? (e.g. Cancer, Hepatitis, eating disorders, high blood pressure, sleep apnoea)
We regularly have studies that allow for/require participants with medical conditions.
Which of the following conditions do you have/have you had?
Cancer
Coeliac disease
Diabetes - Type 1
Diabetes - Type 2
Epilepsy
Gastrointestinal problems
Hepatitis
HIV Positive
Liver problems
Psoriasis
Rheumatoid Arthritis
Eating disorder
Mental health condition
High blood pressure
High cholesterol
Other
Consent to Information Use and Future Contact
Please confirm
By registering your interest, you consent to Nucleus Network using the information you provide to assess your eligibility for a screening visit and to contact you about current or future clinical trial opportunities. You confirm that the information you provide is accurate and complete. You can unsubscribe at any time. View our
privacy policy
for more details.
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Today
About
Leadership team
Medical leadership team
Careers
Participants
How it works
Find a trial
Sponsors
Global network advantage
Expertise
Resources
Resources
FAQs
News
Contact