Vaccine Trials Inquiry

Questionnaire

Thank you for your interest in the work of the Vaccine Trials Inquiry, the remit of which will already have been explained to you. Further and more detailed information is now required by the Inquiry in order to further progress the investigation.

We now ask you to complete this questionnaire by providing as many details as possible. The Inquiry team fully understands that due to age at the time of the vaccine or due to other circumstances, individuals will have difficulty in answering all the questions. However, please do your best in this regard and return the completed questionnaire by Friday, 17^th May 2002 to:

The Vaccine Trials Inquiry, Commission to Inquire into Child Abuse, Floor 2, St. Stephen’s Green House, Earlsfort Terrace, Dublin 2.

Please note that the Commission cannot proceed with your inquiry unless a completed questionnaire is returned.

If you have any difficulty completing the questionnaire or any other problem in relation to it you can telephone us at:

(01) 662 4444 / Callsave 1850 20 11 20 (Republic of Ireland) LoCall 0845 309 8139 (N.I. & U.K.)

Office hours are from 9:30 a.m. to 1:00 p.m. and from 2:00 p.m. to 5:30 p.m.

Reference number:

PLEASE USE BLOCK CAPITAL LETTERS.

ONE LETTER/ FIGURE PER BOX PLEASE

VTI

LEAVE A SPACE BETWEEN WORDS.

*For Office Use Only

PART I YOUR OWN DETAILS:

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1. Current Surname: (What Surname are you now known by?)

2. First Name(s): (What First name(s) do you use today?)

3. Title (Mr., Ms., Miss, Mrs, Prof., Dr, etc.,)

4. Contact address: (Address for correspondence)

5. Contact telephone number(s): (Phone numbers for contact. Home incl. codes, mobile etc.)

6. Surname(s) when a child: (Maiden name, and/or pre-adoption name etc., if applicable.)

7. Date of Birth: (Please be as accurate as possible e.g. 12/12/1912)

YEAR	YEAR	YEAR	YEAR

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1.9. Place of Birth (Please be as precise as possible e.g. number, street, townland, city)

PART II INSTITUTIONS

1. If you spent time as a resident in an institution, please furnish the name of the institution and the date(s), month(s) and year(s), if known, when you were resident

2. Do you remember the name(s) of any of the people in charge of, or working in the institution at the time?

(Please tick relevant box)

If yes, please give details;

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position

(s) in the Institution __________________________________________________

(e.g. manager, teacher, nurse)

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position

(s) in the Institution __________________________________________________

(e.g. manager, teacher, nurse)

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position

(s) in the Institution __________________________________________________

(e.g. manager, teacher, nurse)

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position

(s) in the Institution __________________________________________________

(e.g. manager, teacher, nurse)

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position

(s) in the Institution __________________________________________________

(e.g. manager, teacher, nurse)

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position

(s) in the Institution __________________________________________________

(e.g. manager, teacher, nurse)

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position

(s) in the Institution __________________________________________________

(e.g. manager, teacher, nurse)

(a)

Institution ________________________________________________________

(b)

Name of person(s): _________________________________________________

(c)

Position(s) in the Institution __________________________________________________

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(e.g. manager, teacher, nurse)

PART III VACCINE TRIALS

Note: A Vaccine Trial is an organised programme conducted to test the strength (potency) of a vaccine, the effectiveness of the vaccine, the method by which it is given or the effect on the person vaccinated. A vaccine trial is different to a standard vaccination that is often given in childhood as part of a generally available immunisation programme. A list of childhood immunisation (vaccination) programmes is included at the end of the questionnaire.

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3.1 Do you think that you were involved

3.3 Do you suspect that you may have in a vaccine trial or trials?

been involved in a vaccine trial or trials?

YES

NO

YES

NO

(Please tick relevant box)

(Please tick relevant box)

3.4 If yes, upon what basis do you

3.2 If yes, upon what basis do you think suspect that you may have been

that you were involved in a vaccine involved in a vaccine trial?

trial?

(May be personal recollections, medical

(May be personal recollections, medical records, information received or physical

records, information received or physical evidence including marks ) evidence including marks)

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3.5 Where do you think the vaccine trial(s) took place?

Name and address of institution(s), own home, clinic or other location(s)

1. _______________________________________________________________________________

2. _______________________________________________________________________________

3. _______________________________________________________________________________

4. _______________________________________________________________________________

5. _______________________________________________________________________________

6. ________________________________________________________________________________

3.6 When did the vaccine trial(s) take place?

(Please give as precise a date(s) as possible)

3.7 If you can, please describe the method by which the vaccine was administered?

(Injections, substance placed in nose, sugar lump by mouth etc.)

3.8 Where on your body was the vaccine administered?

(Please give details of location of vaccine(s))

3.9 What were the effects of the vaccine upon you?

(Are you aware of any effects, good or bad, resulting from the vaccine trial?)

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3.10 Were you informed of what was happening?

(Was the vaccine process and reason explained to you?

e.g. how it was going to happen and why)