0 Dead. Abbreviated Title: Ad5 -based combination vaccines Version Date: 05.16.2018 75 13.2 APPENDIX B: INJECTION SITE REACTIONS DIARY CARD Please answer all questions below once per day for the first 7 days Day 0 (Day of Injection) Day +1 Day +2 Day +3 Day +4 Day +5 Day +6 1. Is there redness at the injection site? Circle: Yes / No If yes measure longest diameter in millimeters (mm) Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm 2. Is there firmness or swelling at the injection site? Circle: Yes / No If yes measure longest diameter in millimeters (mm) Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm Yes / No ___________mm 3. Is there soreness at the injection site? Circle: Yes / No If yes tell us if the soreness is mild, moderate, or severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe 4. Have you experienced pain at the injection site? Circle: Yes / No If yes tell us if the pain is mild, moderate, or severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe 5. Have you taken any medication for Circle: Yes / No Provide name and Yes / No Name: ___________ Yes / No Name: ___________ Yes / No Name: ___________ Yes / No Name: ___________ Yes / No Name: ___________ Yes / No Name: ___________ Yes / No Name: ___________ Abbreviated Title: Ad5 -based combination vaccines Version Date: 05.16.2018 76 Day 0 (Day of Injection) Day +1 Day +2 Day +3 Day +4 Day +5 Day +6 injection site pain? dose of medication Dose: ____________ Dose: ____________ Dose: ____________ Dose: ____________ Dose: ____________ Dose: ____________ Dose: ____________ 6. Have you experienced chills? Circle: Yes / No If yes tell us if the chills are mild, moderate, or severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe Yes / No Mild Moderate Severe 7. Record your daily temperatur e (Do not drink anything within 5 minutes prior to taking your temperature) Circle: Yes / No If your temperatur e is 104OF for more than 24 hours, call your study doctor Record Temp: ________________ _ Record Temp: ________________ _ Record Temp: ________________ _ Record Temp: ________________ _ Record Temp: ________________ _ Record Temp: ________________ _ Record Temp: ________________ _