SCOPE COPD Pre-Screening Sign Up Form

Please complete all required questions. You can move back and edit at any point.

Step 1 of 13

What is your age?

Age in years

Do you smoke regularly or did you previously smoke?

Yes, I currently smoke

I used to smoke

How many years roughly have you smoked?

Do you vape?

Yes

Please choose the statement that best describes you.

I have COPD

I am a healthy volunteer without COPD and have not smoked

Neither of the above

Are you able to attend the study site at Cambridge Biomedical Campus?

Yes

Are you registered with a GP practice in the UK?

Yes

Are you already enrolled in a clinical trial?

Yes

Are you currently pregnant, breastfeeding, or planning pregnancy in the next 3 years?

Yes

Not applicable

Are you happy to have CT scans, blood tests and lung function tests?

Yes

Would you be interested in bronchoscopy as part of the study?

This camera test is optional.

Yes

Is it okay if we contact you to arrange a screening visit?

Yes

Contact details

Name

Telephone number

Preferred method of contact

Any preferred time to contact

Consent and data use

I agree for the Study Team to record my personal information and medical history for this study.

I agree

I do not agree

I understand and agree that my medical information will be used to assess eligibility for this study.

I agree

I do not agree

Cambridge University Hospitals NHS Foundation Trust (CUH) is the Sponsor and data controller for this process.

Cambridge University Hospitals NHS Foundation Trust (CUH) is the Sponsor for this observational study based in the United Kingdom. They will be using information from you to send you further information about this study and will act as the data controller for this purpose. This means that they are responsible for looking after your information and using it properly. If you wish deletion of your records, please contact us to do so at any time. To safeguard your rights, we will use the minimum personally-identifiable information possible. You can find out more about how the Sponsor uses your information using the information below: - For Cambridge University Hospitals NHS Foundation Trust, please visit: https://www.cuh.nhs.uk/corporate-information/about-us/our-responsibilities/looking-after-your-information, or email the Data Protection Officer at: [email protected]