Attachment H - Recruitment Data Form

ATTACHMENT H

Recruitment Data Form

Recruitment Data Form

The Natural History of Spina Bifida in Children Pilot Project

RECRUITMENT DATA FORM

1. Name of person filling out form:

2. Time period covered:

mm/dd/yy mm/dd/yy

3. How many families did you attempt to recruit in the past 2 weeks?

4. How many families did you recruit in the past 2 weeks?

5. How were the potential families approached?

The total number should add up to the number in item 3

_____Phone (project staff initiated the phone call)

_____Phone (the potential participant initiated the phone call)

_____Clinic/Hospital

_____Other, specify

6. How many of these families were:

______ Ineligible, specify reason/s

______ Refused to participate, specify reason/s

______ Expressed interest, but did not enroll, specify reason/s

______ Enrolled/recruited, if enrolled specify what component they enrolled in

 Phone survey component

 In-person component

______ Other, please specify

7. How many of the families you attempted to recruit were MACDP families?

8. How many of the families that you did recruit were MACDP families?

9. Describe any problems related to participant recruitment