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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

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Required format:

MINNE-LOVE2 Pre-Screen

Returning?

A A A

Thank you for your interest in the MINNE-LOVE2 study! The goal of this study is to learn more about the specific types of microbes that cause respiratory infections in children and adults across the state of Minnesota over time.

To help us know whether your household is eligible to participate, please provide some additional information below. Once we receive your response, a member of our study team will contact you.

Is there at least one adult in your household willing to complete a short questionnaire each week about respiratory illnesses in household members?

* must provide value

Yes

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Is there at least one adult in your household willing to self collect nasal swabs during episodes of respiratory illness and mail them back to the study team?

* must provide value

Yes

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Does this person have any health concerns that would make it unsafe to provide nasal swabs (for example, severe anxiety about medical procedures, severe immunocompromising condition or a bleeding disorder)?

* must provide value

Yes

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Are there additional household members (adults and/or children) who would be willing to provide nasal swabs during episodes of respiratory illness?

* must provide value

Yes

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You have indicated no adults in your household are willing to complete short questionnaires every week. This is a requirement of the study. If you would like to proceed with the pre-screener, please change your response to "yes".

Contact the study team for any specific questions related to this.

You have indicated no adults in your household are willing to self collect nasal swabs during episodes of respiratory illness. This is a requirement of the study. If you would like to proceed with the pre-screener, please change your response to "yes".

Contact the study team for any specific questions related to this.

Specify the total number of household members (including yourself) who would be willing to provide nasal swabs during the episodes of respiratory illness:	Adults:
	Children:

Total Number of Household Members

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You have exceeded the maximum number of household members who can participate in this study. A maximum of 10 members are eligible to participate. Please adjust your total count of adults and children in the household who would be willing to provide nasal swabs during episodes of respiratory illness

Please provide your contact information so a study team member can follow-up with you.

Name:

Phone:

Email:

Please enter the address of your household.

Address Line 1
Address Line 2
Address Line 3
City
State
Zip Code

Note: This address will be used to mail specimen collection kits for the duration of the study. If your address changes at any point of your potential enrollment in the study, please notify the study staff.

If we could offer surveys in a language other than English, is there a language you would prefer?

Yes

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Please select your preferred language:

Amharic

Arabic (العربية)

Cambodian (ខ្ មែរ )

Hmong (Hmoob)

Karen (ကညီ)

Lao (ພາສາລາວ)

Oromo

Russian (Русский)

Spanish (Español)

Somali (Af-Soomaali)

Vietnamese (Tiếng Việt)

Not listed

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Date of Completion

M-D-Y H:M

Date eConsent(s) for Household completed

M-D-Y H:M

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.