SVMH/STAGE-28 Mental Health Portal

STAGE-28 Trial

Thank you for providing your consent to participate in the STAGE-28 trial at St Vincent’s Hospital Melbourne. This is a reminder that if you wish to withdraw at any time, please let us know, so that your data can be traced and deleted. Contact details, further information and how to raise concerns appear on the Participant Information and Consent Form which can be downloaded here.

Code/ID: *

Two initials plus 4-digit birthday and month For example: for Joe Smith born 24/08/77 enter: ‘JS2408’

Email address: *

Age:

Gender:

Do you identify as Aboriginal or Torres Strait Islander?

Yes

No

Were you, or one of your parents, born overseas?

Yes

No

Do you speak a language other than English?

Yes

No

Years of Service at SVHM:

What is your job role at SVHM?

Which setting do you work in?

Inpatient

Outpatient

My work does not involve direct patient care

What is your typical work shift?

Days

Nights

A combination

Are you qualified in your patient area?

Yes

No

Not applicable

Are you a STAR peer support member?

Yes

No

Are you a graduate student?

Yes

No

In the last 12 months did you…

..work in Covid-19 related areas?

Yes

No

Prefer not to disclose

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..work from home?

Yes

No

Prefer not to disclose

Paragraph

Were you ever quarantined?

Yes

No

Prefer not to disclose

Paragraph

Did you care for a patient with Covid-19?

Yes

No

Prefer not to disclose

Paragraph

Did you care for anyone who died?

Yes

No

Prefer not to disclose

Paragraph

Did you contract Covid-19 yourself?

Yes

No

Prefer not to disclose

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SVHM/STAGE-28 Mental health Portal

Demographics

STAGE-28 Trial

In the last 12 months did you…