Appendix B - Sample Screen Log Study: Site: Investigator: Date of Gender Screening Screening Consent Enrolled Date Screening Birth Date Status Obtained (if no, indicate Enrolled Number (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 mm/dd/yyyy mm/dd/yyyy F No No / / / / / / M Yes Yes mm/dd/yyyy F mm/dd/yyyy No No mm/dd/yyyy Sample Screen Status Codes: 1-Eligible If not eligible, Reason: 1-Inclusion # (specify) 2-Eligible, declined participation 2-Exclusion# (specify) 3-Not Eligible 3-Other (specify) 4-Eligible, lost to follow-up 5-Other, specify in space provided
Appendix B - 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 If not eligible, Reason: 1-Inclusion # (specify) 2-Eligible, declined participation 2-Exclusion# (specify) 3-Not Eligible 3-Other (specify) 4-Eligible, lost to follow-up 5-Other, specify in space provided
startup_mop_multisite.docx