Please enter today's date (MM/DD/YYYY):
Today M-D-Y
Which of the following medical conditions apply:
Cirrhosis
On dialysis
HIV/AIDS
Autoimmune/immune-mediated condition
Castleman disease
Inflammatory bowel disease (Crohn's disease or ulcerative colitis)
Parkinson's disease
Alzheimer's disease
None
What type of Castleman disease do you have?
Unicentric
Multicentric
What type of multicentric Castleman disease do you have?
HHV-8 associated
Idiopathic
What type of dialysis do you currently receive?
In-center hemodialysis
Home hemodialysis
Peritoneal dialysis
Other
Which of the following autoimmune/immune-mediated condition(s) do you have?
Systemic lupus erythematosus (lupus)
Inflammatory arthritis (including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, reactive arthritis, associated with inflammatory bowel diseases - Crohn's disease or ulcerative colitis)
Sjὅgren's syndrome
Myositis
Scleroderma (or systemic sclerosis)
Vasculitis (including polyarteritis nodosa, Behcet's syndrome, polymyalgia rheumatica, temporal arteritis/giant cell arteritis, eosinophilic granulomatosis polyangiitis/Churg-Strauss syndrome, granulomatous polyangiitis/Wegener's granulomatosis, Henoch-Scholein purpura, Microscopic polyangiitis, Takayasu arteritis)
Other
What type of vasculitis do you have?
Are you taking any medications or receiving therapy that suppresses your immune system (immunosuppressant medication)?
Yes
No
Which medications have you taken within the past 3 months (select all that apply):
Adalimumab (Humira®)
Anakinra (Kineret®)
Azathioprine (Imuran®)
Baricitinib (Oluminat®)
Belatacept (Nulojix®)
Belimumab (Benlysta®)
Budesonide (Entocort®)
Certolizumab (Cimzia®)
Cyclophosphamide (Cytoxan®)
Cyclosporine (Neoral®, Sandimmune®, or Gengraf®)
Etanercept (Enbrel®)
Everolimus (Afinitor®)
Golimumab (Simponi®)
Hydroxychloroquine or Chloroquine (Plaquenil®)
Infliximab (Remicade®)
IV or subcutaneous immunoglobulin (IVIg/SCIg) (Gammagard®)
Ixekizumab (Taltz®)
Leflunomide (Arava®)
Methotrexate (Otrexup®, Xatmep®, or Trexall®)
Mycophenolate acid (Myfortic®)
Mycophenolate mofetil (CellCept®)
Natalizumab (Tysabri®)
Ocrelizumab (Ocrevus®)
Plasma exchange or plasmapheresis
Prednisone or other steroids
Rituximab (Rituxan®)
Secukinumab (Cosentyx®)
Sirolimus (Rapamune® or Rapamycin®)
Sulfasalazine (Azulfidine®)
Tacrolimus (Prograf® or Envarsus XR®)
Tocilizumab (Actemra®)
Tofacitinib (Xeljanz®)
Ustekinumab (Stelara®)
Upadacitinib (Rinvoq®)
Other
Please state the name of medication(s):
What dose of prednisone or other steroid do you take?
How often do you get Rituximab (Rituxan®)?
2x/day
Daily
Weekly
Every 2 weeks
Once a month
Other
When was your last rituximab treatment (MM-DD-YYYY)?
Today M-D-Y
What dose of Mycophenolate acid (Myfortic®) do you take in mg ?
How often do you take Mycophenolate acid (Myfortic®)?
2x/day
Daily
Weekly
Every 2 weeks
Once a month
Other
What dose of Mycophenolate mofetil (CellCept®) do you take in mg ?
How often do you take Mycophenolate mofetil (CellCept®)?
2x/day
Daily
Weekly
Every 2 weeks
Once a month
Other
Have you received a COVID-19 vaccine?
Yes
No
Do you intend to receive a COVID-19 vaccine when it becomes available?
Yes
No
Are you enrolled in another study at Johns Hopkins involving collection of blood to determine the presence of COVID-19 antibodies?
Yes
No
Have you received an organ transplant?
Yes
No
We are operating another study for transplant recipients, please visit transplantvaccine.org to learn more. You may now exit this form. Thank you!
Enter your date of birth (MM/DD/YYYY):
Please make sure the year is correct!
Today M-D-Y
What is your weight in pounds (lbs)?
Enter your sex (assigned at birth):
Female
Male
Prefer not to say
What is your racial identity?
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Arab or Middle Eastern
Multi-racial
Prefer not to answer
Do you identify as Hispanic/Latino?
Yes
No
Prefer not to say
What is the highest level of education you completed?
Less than high school
High school or GED
Attended college or technical school
Associate's or Bachelor's degree
Post-college graduate degree
Prefer not to say
Enter your email address:
Enter your cell phone number (XXX-XXX-XXXX):
Enter your home phone number, if applicable (XXX-XXX-XXXX):
Enter your street address (ex. 123 Apple St.):
Enter your apartment/unit number, if applicable:
What is the underlying cause of your liver disease?
Alcoholic liver disease
Fatty liver disease
HCV
HBV
Hemochromatosis
Autoimmune hepatitis
Primary sclerosing cholangitis (PSC)
Primary biliary cholangitis (PBC)
Other
Unknown
Have you or are you being treated for HCV?
I have completed treatment
I am currently in treatment
I have not had treatment
Have you or are you being treated for HBV?
I have completed treatment
I am currently in treatment
I have not had treatment
How long ago did you last drink an alcoholic beverage?
< 24 hrs
1-7 days
7-30 days
30 - 90 days
90 days - 6 months
6 months - 1 year
> 1 year
What complications of cirrhosis have you had (if any)?
Jaundice (yellowish eyes or skin)
Gastrointestinal bleeding (bleeding from your esophagus or intestines)
Confusion
Fluid buildup in the abdomen
Infection of abdominal fluid
Liver cancer
None
What was your last CD4 count?
< 200
200-350
350-499
>/=500
Unknown
Was your most recent viral load "undetectable" according to your doctor?
Yes
No
Unknown
Are you currently taking any antiretroviral therapy (ART)?
Yes
No
How long have you been taking these medications?
Less than 6 months
Greater than 6 months
How often do you receive dialysis?
<1x/week
1x/week
2x/week
3x/week
4x/week
5x/week
6x/week
7x/week
>7x/week
Have you ever been diagnosed with common variable immunodeficiency (CVID), or low immunoglobulin or antibody levels?
Yes
No
Have you been treated with chemotherapy for cancer within the past 6 months?
Yes
No
Do you carry an Epinephrine Auto-Injector (EpiPen®)?
Yes
No
Have you ever had an allergic reaction to a vaccine?
Yes
No
Did this reaction require epinephrine injection?
Yes
No
Which of the following did you experience?
Itchiness
Throat tightness
Shortness of breath
Lightheadedness
GI distress (nausea, vomiting, diarrhea)
Injection site swelling/redness
Hives or welts
Lip and/or tongue swelling
Hoarseness
Wheezing
Other
Within the past 3 months, have you been tested for COVID-19 antibodies?
Yes
No
What date were you tested (MM-DD-YYYY)?
Today M-D-Y
What was the result of your test?
Positive
Negative
Have you ever been diagnosed with COVID-19?
Yes
No
When were you diagnosed (MM/DD/YYYY)?
Today M-D-Y
How did you hear about this research study?
Social media post
Other
Are you a patient at Johns Hopkins Medicine?
Yes
No
Submitting this enrollment form will constitute as consent for enrollment into the study. Please review the consent form before submitting.
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