Volunteer Registration

Summary of procedure

By submitting this form, you are registering interest in donating blood (70 ml) and skin tissue from the posterior (2x 4mm, approximately the size of a hole punch).

The procedures are carried out at minimum one week apart between 8.30 am to 10.30 am on a Monday or Friday at the Royal Victoria Infirmary, Newcastle. You will receive a £50 gift voucher for one set of donations, plus a further £25 for additional bloods if required.

The procedure is entirely voluntary and you may retract consent at any stage.

This study runs an ongoing recruitment with limited slots every week. Therefore if booking dates are currently unavailable, you will have been placed on a waiting list. Recruitment batches occur approximately every 3 months, so we will reach out in due course if no slots are available. Please check your email closer to the dates for updates on booking availabilities. If an email has not come through, please check your spam folders.

Resources

• Alcyomics Study Protocol
• Healthy Volunteers Consent
• Healthy Volunteer Information Sheet
• Healthy Volunteer Eligibility Criteria
• GDPR Compliance Terms

Query line: 0191 580 6157

Email: info@alcyomics.com

Contact

First Name:

Last Name:

Mobile Number:

Email address:

Identifiers

Age:

Ethnicity: Indian Pakistani Bangladeshi Chinese Japanese Mixed Asian background Any other Asian background Caribbean African Any other Black, Black British, or Caribbean background White and Black Caribbean White and Black African White and Asian Any other Mixed or multiple ethnic background English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Roma Any other White background Arab Any other ethnic group

Sex at birth: Select... Male Female

Medical History

Select all allergies that apply:

Penicillin

Wheat-based products

Cosmetics

Pollen or Dust Mites

Pets

List of current and recent medications:

Skin Condition History

Have you ever been diagnosed with psoriasis?

Yes No

Have you ever been diagnosed with atopic dermatitis?

Yes No

Have you ever been diagnosed with any other skin condition other than the above?

Yes No

If yes, please state what skin conditions:

At what age approximately were you first diagnosed?

Do you have a family history of skin disease?

Yes No

If yes, what is their relation to you?

What symptoms have you experienced related to your skin condition?

Red patches of skin

Itching

Scaling

Pain

Dry skin

Blisters

Cracking skin

Other (please specify)

Which areas of the body are most affected?

How would you rate the severity of your condition at its worst? Mild Moderate Severe

How often do you experience flare-ups? Rarely Occasionally Frequently Constantly

When was the last time you experienced symptoms?

Have you identified any triggers that worsen your condition?

Stress

Weather (cold/dry or hot/humid)

Certain foods

Infections

Allergens (e.g., pollen, dust)

Skin injuries (cuts, scrapes, sunburn)

Hormonal changes

Medication

Other (please specify)

What treatments have you tried for your skin condition? (Check all that apply)

Topical creams/ointments

Oral medications

Phototherapy

Biologic treatments

Alternative therapies (e.g., acupuncture, herbal remedies)

Unknown

Other (please specify)

How effective have you found these treatments?

Very effective Somewhat effective Not effective

Is there any other information you believe is relevant to your skin condition?

Have you ever experienced any other inflammatory conditions not related to the skin? E.g. Asthma, Arthritis, Inflammatory Bowel disease etc.

Comments:

Consent

I have read and understood Healthy Volunteers Consent document, and consent to these donations.

I understand that my fully anonymised information can be used for research purposes.

I have read and understood, and comply with the eligibility criteria.

I agree to the GDPR compliance terms.

(Optional) I agree to be recruited again beyond the first donation visit.

Submit