Name
Email Address
Role
Care Home Name
Care Home Address
1. Are you interested in using a contact tracing system in your home? YesNo (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? YesNo
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? YesNo (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? YesNo
4a. if yes, please provide name of organisation:
5. When could you start Research activity? AprilMayJuneJulyAugust (Training, Resident and Staff recruitment, Contact tracing installation, and information collection)
