CONTACT Study Interest Form

    Name

    Email Address

    Role

    Care Home Name

    Care Home Address

    1. Are you interested in using a contact tracing system in your home?

    (Do you think Residents, Staff, and Visitors in your home would be willing to wear a small device (key fob/watch)?)

    2. Are you taking part in any other Research at the moment?

    2a. if yes, please provide study name:

    2b. if yes, what is the research focus?
    (eg. COVID-19 / Infection Prevention / Other – please specify)

    3. Do you have staff able to support research activity?

    (Key activity will include; Training/Resident and Staff recruitment,and information collection)

    4. Are you part of an organisation with multiple homes in Yorkshire / Midlands?

    4a. if yes, please provide name of organisation:

    5. When could you start Research activity?

    (Training, Resident and Staff recruitment, Contact tracing installation, and information collection)