PRECONSENT FOLLOW UP RESEARCH SUBJECT & STUDY STATUS FORM TO UPDATE EPIC (Revised 02/17) Date: Name of Requestor: Phone: This form should be completed and emailed to when a Pre-consent OR Follow Up research indicator needs to be assigned or removed in Epic. NOTE: Prec-onsent indicator is only necessary if you need to schedule a research visit or place a research order PRIOR to subject signing consent. IRB # Industrial Research Subject Name MRN Add/Remove Remove Account # (if Preconsent Preconsent known) OR Reason Follow-Up (ex.) 1234 100009999 Subject 1 456789123 Remove Ineligible Declined
RESEARCH SUBJECT PRECONSENT & FOLLOW UP STUDY STATUS FORM TO UPDATE EPIC (Revised 02/17) Date: Name of Requestor: Phone: This form should be completed and emailed to when a Pre-consent OR Follow Up research indicator needs to be assigned or removed in Epic. NOTE: Prec-onsent indicator is only necessary if you need to schedule a research visit or place a research order PRIOR to subject signing consent. IRB # Industrial Account # (if known) Research Subject Name MRN Add/Remove Preconsent OR Follow-Up Remove Preconsent Reason (ex.) 1234 100009999 Subject 1 456789123 Remove Ineligible Declined
RESEARCH_SUBJECT_STUDY_STATUS_CHANGE_FORM-Revised-02-23-2017.docx