Appendix A. Sample Screen Log Study: Site: Investigator: Screening Date of Gender Screening Screening Consent Enrolled Date Number Birth Date Status Obtained (if no, indicate Enrolled (use codes reason from below) below) / / M / / Yes Yes / / mm/dd/yyyy F mm/dd/yyyy No No mm/dd/yyyy / / M / / Yes Yes / / mm/dd/yyyy F mm/dd/yyyy No No mm/dd/yyyy / / M / / Yes Yes / / mm/dd/yyyy F mm/dd/yyyy No No mm/dd/yyyy / / M / / Yes Yes / / mm/dd/yyyy F mm/dd/yyyy No No mm/dd/yyyy / / M / / Yes Yes / / mm/dd/yyyy F mm/dd/yyyy No No mm/dd/yyyy 2-Eligible, declined participation 2-Exclusion# (specify) Sample Screen Status Codes: 3-Not Eligible If not eligible, reason: 3-Other (specify) 4-Eligible, lost to followup 5-Other, specify in space provided 1-Eligible 1-Inclusion # (specify)
Appendix A. Sample Screen Log Study: Site: Investigator: Screening Number Date of Birth Gender Screening Date Screening Status (use codes below) Consent Obtained Enrolled (if no, indicate reason from below) Date Enrolled / / mm/dd/yyyy M F / / mm/dd/yyyy Yes No Yes No / / mm/dd/yyyy / / mm/dd/yyyy M F / / mm/dd/yyyy Yes No Yes No / / mm/dd/yyyy / / mm/dd/yyyy M F / / mm/dd/yyyy Yes No Yes No / / mm/dd/yyyy / / mm/dd/yyyy M F / / mm/dd/yyyy Yes No Yes No / / mm/dd/yyyy / / mm/dd/yyyy M F / / mm/dd/yyyy Yes No Yes No / / mm/dd/yyyy Sample Screen Status Codes: 1-Eligible 2-Eligible, declined participation 3-Not Eligible 4-Eligible, lost to followup 5-Other, specify in space provided If not eligible, reason: 1-Inclusion # (specify) 2-Exclusion# (specify) 3-Other (specify)
MOP_NCCIH_ver1_07-17-2015.docx