SUBJECT SCREENING LOG PROTOCOL ID: Principal Investigator: Page __ of __ Complete this log for every subject screened for inclusion in the study. Informed consent must be signed prior to commencement of any screening procedure. If enrolled, record Date subject If not enrolled, Subject allocated Study Subject Gender Date of Informed Date of screened for record reason for exclusion (specify) Enrolled? Subject ID number Initials birth consent Consent eligibility (yes/no) (Enter subject on signed? Enrollment Log) * M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N *If consent is refused, record reason in right-hand column Form version X.X, dated DD MMM YYYY
SUBJECT SCREENING LOG Page __ of __ PROTOCOL ID: Principal Investigator: Complete this log for every subject screened for inclusion in the study. Informed consent must be signed prior to commencement of any screening procedure. Subject Initials Gender Date of birth Informed consent signed? * Date of Consent Date subject screened for eligibility Subject Enrolled? (yes/no) If enrolled, record allocated Study Subject ID number (Enter subject on Enrollment Log) If not enrolled, record reason for exclusion (specify) M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N M F Y N Y N *If consent is refused, record reason in right-hand column Form version X.X, dated DD MMM YYYY