Self Checker Form

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A clinical assessment multi-step form that will assist individuals on deciding when to seek testing or medical care if they suspect they or someone they know has contracted COVID-19 or has come into close contact with someone who has COVID-19

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I agree to the Privacy Policy and Terms and Conditions

I agree to participate in surveys and other market research activities

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I agree to the collection and or sharing of my mobile advertising identifiers or other identifiers

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I agree to share my profile information with third-parties for market research purposes

I agree to share my sensitive data for market research purposes

Provide us with your personal information:

1.Q How would you characterize the place where you live?

2.Q What type of research (except online surveys) are you interested to be invited to participate in? (Additional incentives are paid)?

Q.3 Does the computer you primarily use to interact with research studies have a web camera?

Q.4 Would you be willing to participate in a research study that reads your facial expressions to analyse emotional response? The data is fully anonymous and would be used for research purposes only.

Q.5   Do you agree to opt-in and participate in types of research that may require you to download an application (on mobile, PC or tablet) that will track your online behaviour?

Q.6 Do you agree to opt-in and participate in types of research that may require cookies to be dropped onto your Mobile/PC/Tablet that will track your exposure to certain advertising?

Q.7 What is your highest level of education?

Q.8 What year will/did you graduate from university/college?

Q.9 On average, how many hours of television do you watch per week?

Q.10 Do you smoke?

Q.11 What brand of cigarettes do you smoke?

Q.12 On average, how many cigarettes do you smoke in a day?

Q.13 Do you have access to a car?

Q.14 Are you the primary decision maker in your household for automotive-related purchases?

Q.15 How many cars are there in your household (including leasing or company cars)?

Q.16 If you own/lease a car(s), which brand are they?

Q.17 How would you describe the car(s) you own/lease?

Q.18 What year was your main car (owned or leased) manufactured?

Q.19 Do you own a motorcycle

Q.20 If you own a two wheeled vehicle, which brand are they?

Q.21 If you own a two wheeled vehicle, what engine capacity does it have?

Q.22 If you own a two wheeled vehicle, how would you describe it?

Q.23 If you own/lease a car(s), what fuel do they use

Q.24 Are you considering buying or leasing a new or used car within the next 2 years?

Q.25 What is your current occupational status?

Q.26 What is your occupation?

Q.27 Which of the following categories best describes your organisation's primary industry?

Q.28  Approximately how many employees work at your organisation (all locations)?

Q.29  Which department do you primarily work within at your organisation?

Q.30  If you work in your organisation's IT department, please provide more detail about your role.

Q.31  What is your primary role in your organisation?

Q.32  What is your professional position in the organisation you work for?

Q.33  Have you been diagnosed with any of the following illnesses/conditions? Note that the information will be kept in strictest confidence.

Q.34  If you stated that you have been diagnosed with cancer, can you define the type of cancer?

Q.35  If you stated that you have been diagnosed with diabetes, can you define the type of diabetes?

Q.36  Do you use glasses or contact lenses?

Q.37  Do you use a hearing aid?

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