COVID-19 Registry

Consent Form for Participation in the COVID-19 Registry

The COVID-19 Registry will serve as a data gathering and sharing platform to help health departments better understand the spread and impact of coronavirus disease (COVID-19). This registry will provide real time information on WHO is being affected and HOW and support planning for health department responses to COVID-19.

If you choose to participate, you will be asked to complete a survey with questions about your background and changes in your health, behavior and daily life due to COVID-19. The survey will take between 10-15 minutes to complete depending on your experiences. You will also be asked to complete short 5-minute follow-up surveys every two weeks to help track changes over the duration of the pandemic. Some questions are required. The survey is open to any adult aged 18 or older, whether or not you tested positive for COVID-19. Participation is voluntary, and you may skip questions or stop at any time.

Data from the registry will be stored in a highly secure system built by Rice University. Things that we learn from the registry will be published, but will not include any information that would identify you or any other participant. No one will see your data that does not have permission to see it.

For some participants, questions about COVID-19 may be distressing. If you do feel distressed, free 24/7 counseling and support is available from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Disaster Distress Helpline at 1-800-985-5990, or by texting “TalkWithUs” to 66746.

We are committed to protecting your privacy and maintaining confidentiality. If you have any additional questions about the study, you can contact Dr. Marie Lynn Miranda, the project’s lead investigator, or Rashida Callender at . If you have questions about your rights as a research participant, you should contact Joanna Espinoza, the Rice University Compliance Administrator, at or 713-348-3586.

By clicking “I agree” below, you are indicating that you are at least 18 years old, have read and understood this consent form, and agree to participate in this research study. Please print a copy of this page for your records.

The COVID-19 Registry is a joint venture of Chambers County, Corpus Christi Nueces County Public Health District, Environmental Defense Fund, Fort Bend County Health & Human Services, Gulf Coast Center for Precision Environmental Health, Harris County Public Health Department, Houston Health Department, Montgomery County, Texas Parks & Wildlife Department, Victoria Emergency Management, and Rice University. Please send any comments or questions to — Privacy Policyv1.14