Survey

Platform Randomised trIal of treatmeNts in the Community
for epIdemic and Pandemic iLlnEsses - PRINCIPLE

Participant Registration

Screening Form

Thank you for considering participating in the PRINCIPLE trial.
If you have not already read the Participant Information Leaflet you can download it by clicking the link below.

Click here to download the PRINCIPLE Participant Information Leaflet

There is also an illustrated summary of the Participant Information Leaflet that you can download by clicking the link below:

Click here to download an illustrated summary of the PRINCIPLE Participant Information Leaflet

Click here to access translated versions of the PRINCIPLE Participant Information Leaflet

To start your registration, please complete this screening form.

After you have answered all the questions on this form
please click the "Submit" button at the bottom of the page to proceed to your Consent Form

Please select your age range

Less than 18 18 to 49 50 to 64 65 and above

Are you currently admitted in hospital?

Yes No

Have you previously participated in the PRINCIPLE trial?

Yes No

Your answers to these questions are for safety reasons and will let us know if you will need to take a pregnancy test if you are allocated to certain medication.

Are you pre-menopausal and capable of becomming pregnant?

* If you are in a single-sex relationship, with no chance of becoming pregnant, please answer "No".

** This includes women on any type of contraception; women who are single; women whose partners have been vasectomised or whose partners have received or are using other contraception devices.

Yes No

Are you using a highly effective method of contraception* and prepared to use this for the 28 days of the study?

* The implant, the coil, and male or female sterilisation will be acceptable for participating in the trial. The injection and most forms of hormonal contraception will also be considered acceptable for the trial, if used in combination with condoms or other barrier methods. However, condoms alone won’t be sufficient during the study.
You can discuss any questions you have about contraception during the study period with the trial team.

Yes No

Are you pregnant or planning on becoming pregnant within the next few weeks?

Yes No

Are you breastfeeding or planning on starting during the course of the trial?

Yes No

Do you have a sexual partner who is pre-menopausal and capable of becoming pregnant?

* If you are in a single-sex relationship, with no chance of either partner becoming pregnant, please answer "No".

Yes No

Is your female sexual partner using a highly effective method of contraception* and prepared to use this for the 28 days of the study?

* The implant, the coil, and male or female sterilisation will be acceptable for participating in the trial. The injection and most forms of hormonal contraception will also be considered acceptable for the trial, if used in combination with condoms or other barrier methods. However, condoms alone won’t be sufficient during the study.
You can discuss any questions you have about contraception during the study period with the trial team.

Yes No

Do you have severe liver disease?

Yes No

Do you have a known allergy to favipiravir?

Yes No

Are you currently taking favipiravir?

Yes No

Do you have a known history of gout?

Yes No

If other, please specify

After you have answered all the questions on this form and clicked "I'm not a robot" below
please click the "Submit" button at the bottom of the page to proceed to your Consent Form

PRINCIPLE Participant Registration v19.0 25-01-2022
REC Number: 20/SC/058, IRAS Number: 281958, EudraCT Number: 2020-001209-22, Chief Investigator: Professor Christopher Butler