Screening and Enrollment Log Date Enrollment Screening Date Screening Failure/ Screening Window (or NA if not Discontinuation Date Screening Failure/ Screening Date(s) Participant Closes enrolled) (or NA if enrolled) Discontinuation Code Staff Initials No. Attempt DD-MM-YYYY ID (PTID) DD-MM-YYYY DD-MM-YYYY DD-MM-YYYY (or NA if enrolled) and Date
Screening and Enrollment Log No. Screening Attempt Screening Date(s) DD-MM-YYYY Participant ID (PTID) Date Screening Window Closes DD-MM-YYYY Enrollment Date (or NA if not enrolled) DD-MM-YYYY Screening Failure/ Discontinuation Date (or NA if enrolled) DD-MM-YYYY Screening Failure/ Discontinuation Code (or NA if enrolled) Staff Initials and Date
MTN-023%20Screening%20and%20Enrollment%20Log_14Mar2014.docx