Facility Staff Medical Record Abstraction

Medical Monitoring Project

Attachment6d_SPVisit Form

Facility Staff Medical Record Abstraction

OMB: 0920-0740

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Attachment 6d


Surveillance Period Visit Form


OMB NO: 0920-0740

EXPIRATION DATE: 06/30/2010



Medical Monitoring Project (MMP)

Medical Record Abstraction Form

2008 Surveillance Period Visit Form (SPVF)

VERSION 3.0.0


Public reporting burden of this collection of information is estimated to average 3 minutes per patient record pulled, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0740). Do not send the completed form to this address.









O PTIONAL- FOR LOCAL USE ONLY



M MP SPVF v3.0.0

Abstraction

MMP Participant ID: Facility ID:

(ID of the facility where abstraction is being conducted)


Date of Visit: Date not documented







Medical record number:




Patient name:



Patient residence:




Street:


City/County: State:



ZIP code:




Physician name:






DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control & Prevention


M edical Monitoring Project (MMP)

Medical Record Abstraction Form

2008 Surveillance Period Visit Form (SPVF) v3.0.0



I. ABSTRACTION AND IDENTIFICATION












MMP Participant ID:


Surveillance Period (SP)


SP start date:



(12 months prior to date of interview OR 1st

contact attempt if no interview obtained)



SP end date:



(date of interview OR 1st contact attempt if no

interview obtained)



Date of abstraction: Abstractor ID:


Date of visit:


This visit for laboratory tests only Complete Sections I, X, and XI



Abstraction

Facility ID:


(ID of the facility where abstraction is being conducted)





Was the documented care abstracted with this form given at another facility (i.e., outside the

Abstraction Facility)?





Yes

Complete information about the “Care” Facility


Enter Care Facility ID or indicate that Care Facility was not documented or was outside jurisdiction:


Care

Facility ID



(ID of the facility where the documented care was provided)







No

Continue to Section II below


Care Facility not documented or outside jurisdiction

II. PATIENT WEIGHT





Weight during this visit (lbs): lbs. Weight not documented



III. SURVEILLANCE PERIOD VISIT FORM SECTIONS - OPTIONAL


Is there documentation of any of the following during this visit?

Yes Select all that are documented below.

No This form is now complete except for optional section XII (Remarks).


New or existing diagnoses of AIDS defining opportunistic

illnesses (AIDS OI)

Complete section IV.



Prescription or continuation of antiretroviral therapy (ART)

Complete section VIII.


New or existing diagnoses of conditions other than AIDS OI

Complete section V.


Prescription or continuation of medications other than ART

Complete section IX.


Prescription for prophylaxis of Pneumocystis jiroveci pneumonia

(PCP) or Mycobacterium avium complex (MAC)

Complete section VI.


Frequently repeated laboratory tests

Select this box, and complete section X on visit form for

the date the specimen was collected.


Sexually transmitted infections (STIs)

Complete section VII.


Other laboratory tests, including HIV ART resistance tests

Select this box, and complete section XI on visit form for

date the specimen was collected.



IV. AIDS DEFINING OPPORTUNISTIC ILLNESSES (AIDS OI)


Is there documentation of any new or existing diagnoses of AIDS defining opportunistic illnesses (AIDS OI) during this visit?

Yes Select all that are documented below.

No



1


Candidiasis, bronchi, trachea, or lungs


2


Candidiasis, esophageal


3


Carcinoma, invasive cervical


4


Coccidioidomycosis, disseminated or extrapulmonary


5


Cryptococcosis, extrapulmonary


6


Cryptosporidiosis, chronic intestinal (>1 month duration)


7


Cytomegalovirus disease (other than in liver, spleen, or lymph nodes)


8


Cytomegalovirus retinitis (with loss of vision)


9


Herpes simplex: chronic ulcer (>1 month duration) or bronchitis, pneumonitis, or esophagitis


10


HIV encephalopathy


11


Histoplasmosis, disseminated or extrapulmonary


12


Isosporiasis, chronic intestinal (>1 month duration)


13


Kaposi’s sarcoma


14


Lymphoma, Burkitt’s (or equivalent term)


15


Lymphoma, immunoblastic (or equivalent term, IBL)


16


Lymphoma (primary in brain)


17


Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary


18


M. tuberculosis, pulmonary


19


M. tuberculosis, disseminated or extrapulmonary


20


Mycobacterium, of other species or unidentified species, disseminated or extrapulmonary


21


Pneumocystis jiroveci pneumonia (PCP)


22


Pneumonia, recurrent in 12 month period


23


Progressive multifocal leukoencephalopathy (PML)


24


Salmonella septicemia, recurrent


25


Toxoplasmosis of brain


26


Wasting syndrome due to HIV



V. CONDITIONS OTHER THAN AIDS OI


Is there documentation of any new or existing diagnoses of conditions other than AIDS OI during this visit?

Yes Select all that are documented below.

No


1 Abscess



19 Erythema multiforme


37 Hypogonadism (gonadal

deficiency)



55 Prostatitis


2 Alcoholism


20 Erythroderma


38 Hypothyroidism


56 Psoriasis



3 Anxiety disorder



21 Fatty liver




39 Ischemic heart disease


57 Psychosis, including

schizophrenia


4 Arthritis (osteoarthritis)


22 Fever, unexplained,

>100F for 2+ weeks*



40 Lactic acidosis



58 Pulmonary hypertension


5 Asthma


23 Gastroesophageal reflux

disease (GERD)



41 Lipoatrophy



59 Rash, drug-related


6 Avascular necrosis


24 Guillain-Barré syndrome


42 Lipodystrophy


60 Renal failure


7 Buffalo hump


25 Hearing loss, acquired


43 Malignancy


61 Respiratory infection, upper


8 Bronchitis


26 Hepatic (liver) failure


44 Metabolic syndrome

62 Respiratory infection, NOS


9 Cardiomyopathy, due to

HIV or unknown cause


27 Hepatitis, alcohol-induced


45 Myelopathy (spinal cord

disease/disorder)



63 Seborrheic dermatitis


10 Cellulitis (skin infection,

bacterial)


28 Hepatitis, drug-induced


46 Myopathy (muscular

weakness or changes)


64 Stevens-Johnson

Syndrome


11 Depression, diagnosed by

physician


29 Hepatitis, infectious, not

drug-induced


47 Nephrolithiasis (kidney

stone)



65 Stroke, ischemic, non-

hemorrhagic


12 Diabetes mellitus (DM),

type 1



30 Hepatitis, NOS


48 Nephropathy (kidney

damage)



66 Suicide attempt


13 Diabetes mellitus (DM),

type 2


31 Hodgkin’s lymphoma

(Hodgkin’s disease)


49 Neuropathy, cranial


67 Thrombocytopenia,

idiopathic (ITP)



14 Diabetes mellitus (DM), NOS


32 Human papillomavirus

(HPV) infection



50 Neuropathy, peripheral


68 Vision loss, moderate or

severe; blindness


15 Diarrhea, allergic/colitis



33 Hypercholesterolemia


51 Neuropathy, NOS


69 Warts, anal or genital



16 Diarrhea, infectious



34 Hyperglycemia


52 Oral candidiasis (thrush)


70 Warts, non-anal, non-

genital



17 Diarrhea, NOS


35 Hypertension (high blood

pressure)


53 Osteopenia or

osteoporosis

*in absence of a known cause


18 Erectile dysfunction


36 Hypertriglyceridemia


54 Pneumonia





71 Other, specify:




72 Other, specify:




73 Other, specify:



74 Other, specify:




75 Other, specify:





76 Other, specify:




77 Other, specify:

VI. PROPHYLAXIS


Is there documentation of prescription for prophylaxis of Pneumocystis jiroveci pneumonia (PCP) during this visit?

Yes No


Prescription must be for PCP prophylaxis. Medications include:

Bactrim® (Septra, Cotrim, Co-trimoxazole, trimethorprim, sulfamethoxazole)

Dapsone®

Pentamidine® (pentamidine isothianate)

Mepron® or Mepron® Suspension (atovaquone)

Clindamycin® (clindamycin hydrochloride) + Primaquine® (primaquine phosphate)

Dapsone® + Daraprim®  (pyrimethamine) + Folinic Acid



Is there documentation of prescription for prophylaxis of Mycobacterium avium complex (MAC) during this visit?

Yes No


Prescription must be for MAC prophylaxis. Medications include:

Biaxin Filmtab® (clarithromycin)

Biaxin Granules®

Biaxin XL®

Zithromax®

Zithromax Single Pack® (azithromycin, azithromycin dihydrate)

Mycobutin® (rifabutin)


VII. SEXUALLY TRANSMITTED INFECTIONS (STIs)


Is there documentation of any new or existing diagnoses* of sexually transmitted infections during this visit?

Yes Select all that are documented below.

No


1 Cervicitis


5 Lymphogranuloma venereum (LGV)


9 Syphilis, NOS


13 STI not specified


2 Chancroid


6 Pelvic inflammatory disease (PID)


10 Urethritis, gonoccocal


*For this section, abstract only the medical provider’s explicit documentation of any of these conditions as a clinical diagnosis.



3 Epididymitis



7 Proctitis / proctocolitis


11 Urethritis, non-gonococcal

(non-gonococcal urethritis, NGU)



4 Genital Herpes



8 Syphilis, primary or secondary



12 Urethritis, NOS



14 Other, specify:




15 Other, specify:





16 Other, specify:




17 Other, specify:

VIII. ANTIRETROVIRAL THERAPY (ART)


Is there documentation of prescription or continuation of antiretroviral therapy (ART) during this visit?

Yes Select all that are documented below.

No



1 Abacavir (ABC, Ziagen)



9 Efavirenz (EFV, Sustiva)


17 Lopinavir/Ritonavir

(LPV/RTV, Kaletra, Meltrex)



25 Tenofovir (TDF, Viread)


2 Amprenavir (APV,

Agenerase)



10 Emtricitabine (FTC, Emtriva)



18 Maraviroc (MRC, Selzentry)



26 Tipranavir (TPV, Aptivus)



3 Atazanavir (ATV, Reyataz)


11 Enfuvirtide (ENF, T-20,

Fuzeon)



19 Nelfinavir (NFV, Viracept)



27 Trizivir (ABC/3TC/AZT)



4 Atripla (EFV/FTC/TDF)



12 Epzicom (ABC/3TC)



20 Nevirapine (NVP, Viramune)


28 Truvada (FTC/TDF)



5 Combivir (AZT/3TC)


13 Etravirine (ETR, Intelence,

formerly TMC125)


21 Raltegravir (RAL, Isentress,

formerly MK-0518)



29 Zalcitabine (ddC, Hivid)


6 Darunavir (DRV, TMC 114,

Prezista)


14 Fosamprenavir (FPV, Lexiva)



22 Ritonavir (RTV, Norvir)


30 Zidovudine (AZT,

Retrovir)


7 Delavirdine (DLV,

Rescriptor)



15 Indinavir (IDV, Crixivan)


23 Saquinavir (SQV-HGC,

Invirase, Fortovase)



8 Didanosine (ddl, Videx)



16 Lamivudine (3TC, Epivir)


24 Stavudine (d4T, Zerit)




31 Other,

Specify:



32 Other,

Specify:



33 Other,

Specify:



34 Other,

Specify:


IX. OTHER MEDICATIONS


Is there documentation of prescription or continuation of medications other than ART during this visit?

Yes Select all that are documented below.

No


1

acarbose


48

esomeprazole


2

acetominophen/hydrocodone


49

ethambutol


3

acetominophen/oxycodone


50

ethionamide


4

acyclovir


51

famotidine


5

adefovir


52

fexofenadine


6

albuterol


53

filgrastim


7

albuterol/ipratropium


54

folinic acid


8

aldesleukin


55

fluconazole


9

alprazolam


56

fludrocortisone


10

amikacin


57

fluoxetine


11

amitriptyline


58

fluphenazine


12

amitriptyline/chlordiazepoxide


59

fluticasone


13

amoxicillin


60

fluticasone/salmeterol


14

amoxicillin/clavulanate


61

fluvastatin


15


aspirin (ASA)


62

foscarnet


16

atenolol


63

gabapentin


17

atorvastatin


64

gatifloxacin


18

azithromycin


65

gemfibrozil


19

baclofen


66

hydrochlorothiazide (HCTZ)


20

bupropion


67

hydrochlorothiazide (HCTZ)/methyldopa


21

buspirone


68

hydrochlorothiazide (HCTZ)/metoprolol


22

butalbital/aspirin


69

hydrochlorothiazide (HCTZ)/triamterene


23

butalbital/aspirin/caffeine (BAC)


70


imiquimod


24

calcitrol


71

insulin (inhaled or injectable)


25

capreomycin


72

interferon alphacon-1


26

cetirizine


73

interferon alfa 2a


27

chlorpropamide


74

interferon alfa 2b


28

cimetidine


75

iodoquinol


29

ciprofloxacin


76

isoniazid (INH)


30

citalopram


77

isoniazid (INH)/pyrazinamide (PZA)/rifampin


31

clonazepam


78

isoniazid (INH)/rifampin


32

cromolyn


79

kanamycin


33

cycloserine


80

lansoprazole


34

cyclosporine


81

lansoprazole/amoxicillin/clarithromycin


35

dapsone (DDS)


82

levofloxacin


36

darifenacin


83

levothyroxine


37

dexamethasone


84

lisinopril


38

diphenhydramine


85

lithium


39


doxorubicin


86

loxapine


40

doxorubicin lipsomal


87

megestrol


41

doxycycline


88

metformin


42

dronabinol


89

methadone


43

enalapril


90

metoclopramide


44

enalapril/hydrochlorothiazide (HCTZ)


91

metoprolol


45

entecavir


92

mirtazapine


46

epoetin alfa (EPO)


93

moxifloxacin


47

escitalopram


94

nalbuphine


IX. OTHER MEDICATIONS cont’d


95


niacin


121

rifampin


96

nifedipine


122

rifapentine


97

nizatidine


123

rosiglitazone


98

octreotide


124

rosiglitazone/glemepiride


99

olanzapine


125

rosuvastatin


100

omeprazole


126

sertraline


101

oxycodone


127

sildenafil


102

p-aminosalicylate


128

somatropin


103

palonosetron


129

streptomycin


104

pantoprazole


130

tadalafil


105

paroxetine


131

tamsulosin


106

peginterferon alfa 2a


132

telbivudine


107

peginterferon alfa 2b


133

testosterone


108

penicillin


134

tinidazole


109


phenytoin


135

trazadone


110

pioglitazone


136

triamcinolone nasal


111

podofilox topical


137

trichloracetic acid (TCA) topical


112

podophyllin topical


138

trimethoprim/sulfamethoxazole (TMP/SMZ)


113

pravastatin


139

valacyclovir


114

prednisone


140

valproic acid


115

propranolol


141

vancomycin


116

propranolol/hydrochlorothiazide (HCTZ)


142

vardenafil


117


pyrazinamide (PZA)


143

venlafaxine


118

ranitidine


144

warfarin


119

ribavirin


145

zanamivir


120

rifabutin


146

zolpidem


1 47 Other,

Specify:


1 48 Other,

Specify:


1 49 Other,

Specify:


1 50 Other,

Specify:


1 51 Other,

Specify:

X. LABORATORY TESTING – FREQUENTLY REPEATED TESTS


Is there documentation of any of the following frequently repeated laboratory tests done at this visit?

Yes Enter all that are documented below on the visit form for the date the specimen was collected.

No

CD4 & HIV Viral Load


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


1 CD4 cell count







Cells/ mm3 or µL


Other, specify: __________________________


Units not

documented


2 CD4 cell %







%


Units not

documented


3 HIV viral load







Copies/mL


Other, specify: __________________________


Units not

documented


Lower Limit of Detection for HIV Viral Load Test Used:

Lower Limit NOT documented




X. LABORATORY TESTING – FREQUENTLY REPEATED TESTS cont’d


glucose regulation tests


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


4 FBG (FBS,

Fasting blood glucose)







mg/dL


Other, specify: __________________________



Units not

documented


5 Hemoglobin A1c

(HbA1c)







%


hematology Tests


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


6 WBC

(White blood cell

Or Leukocyte count)







Thousands/ mm3 or µL (x103 / mm3 or µL)


Other, specify: __________________________


Units not

documented


7 RBC (Red blood cell

Or Erythrocyte count)







Millions/ mm3 or µL (x106 / mm3 or µL)


Other, specify: __________________________


Units not

documented


8 Hemoglobin

(Hgb, Hb)







g/dL


Other, specify: __________________________


Units not

documented


9 Platelet count

(PLT, Thrombocyte count)






Thousands/ mm3 or µL (x103 / mm3 or µL)


Other, specify: __________________________


Units not

documented

lipid levels


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


10 Cholesterol,

HDL (HDL-C)







mg/dL


Other, specify: __________________________


Units not

documented


11 Cholesterol,

LDL (LDL-C)







mg/dL


Other, specify: __________________________


Units not

documented


12 Cholesterol,

Total







mg/dL


Other, specify: __________________________


Units not

documented


13 Triglycerides

(TG, TRIG)







mg/dL


Other, specify: __________________________


Units not

documented

Liver function tests (LFTs)


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


14 Albumin (ALB)







g/dL


Other, specify: __________________________


Units not

documented


15 ALT (SGPT)







Units /L


Other, specify: __________________________



Units not

documented


16 AST (SGOT)







Units/L


Other, specify: __________________________



Units not

documented


17 Bilirubin, total







mg/dL


Other, specify: __________________________



Units not

documented

Renal function Tests


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


18 Creatinine (Creat, Cr)







mg/dL


Other, specify: __________________________



Units not

documented


19 Urine protein,

dipstick




mg/dL


Other, specify: __________________________



Units not

documented

XI. LABORATORY TESTING – OTHER TESTS


Is there documentation of any of the following other laboratory tests done at this visit?

Yes Enter all that are documented below on the visit form for the date the specimen was collected.

No

CHEMISTRY Tests


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


20 Urine protein,

24 hour







mg/24 hours


Other, specify: __________________________



Units not

documented


21 Urinary hCG

(Urine pregnancy test, UPT)







XI. LABORATORY TESTING – OTHER TESTS cont’d


INFECTIOUS DISEASE TESTS: Hepatitis A, B, C

Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


22 Anti-HAV IgG

(HAV Ab IgG)







23 Anti-HAV IgM

(HAV Ab IgM)







24 Anti-HAV total

(HAV Ab total)







25 Anti-HBc IgG

(HBc Ab IgG)







26 Anti-HBc IgM

(HBc Ab IgM)







27 Anti-HBc total

(HBc Ab total)







28 Anti-HBe (HBe Ab)







29 Anti-HBs IgG

(HBs IgG Ab)








30 Anti-HBs total

(HBs Ab)








31 HBeAg

(Hepatitis B e-antigen)







32 HBsAg

(Hepatitis B surface antigen)







33 HBV DNA (PCR)



IU/mL


Other, specify: _________________________


Units not

documented


Lower Limit of Detection for HBV DNA (PCR) Test Used:

Lower Limit NOT documented





Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


34 Anti-HCV, EIA, or RIBA







35 HCV genotype










36 HCV RNA qualitative






37 HCV RNA quantitative

(PCR)





IU/mL


Other, specify: ________________________


Units not

documented


Lower Limit of Detection for HCV RNA (PCR) Test Used:

Lower Limit of Detection NOT documented



INFECTIOUS DISEASE TESTS: Human Papillomavirus (HPV), Syphilis, Toxoplasma


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)

38 HPV DNA (PCR)











IU/mL


Other, specify: ________________________


Units not

documented



Lower Limit of Detection for HPV DNA (PCR) Test Used:

Lower Limit of Detection NOT documented



39 Dark field microscopy

(Immunofluorescent stain

for T. pallidum / syphilis)









40 FTA-ABS (FTA,

Treponemal syphilis test)








41 RPR (Non-treponemal

syphilis test)





titer








42 TPHA (TP-PA, MHA-TP,

Treponemal syphilis test)








43 VDRL (Non-treponemal

syphilis test)




titer





44 Anti-Toxoplasma IgG







XI. LABORATORY TESTING – OTHER TESTS cont’d

INFECTIOUS DISEASE TESTS: Chlamydia, Gonorrhea, Trichomonas


45 Chlamydia Tests

(CT, C. trachomatis tests)

Result

Site of Specimen Collection (select one for each test performed)

Pos(+)

Neg(-)

Indeterminate

Anorectal

Cervical

Lymph node

Ocular

Pharyngeal

Urethral (swab)

Urine

NOS


1


Culture













2


DFA*













3


EIA (ELISA)













4


NAAT













5


Nucleic acid probe













6


Test not specified














46 Gonorrhea Tests

(GC, N. gonorrhoea tests)

Result

Site of Specimen Collection (select one for each test performed)

Pos(+)

Neg(-)

Indeterminate

Anorectal

Cervical

Lymph node

Ocular

Pharyngeal

Urethral (swab)

Urine

NOS


1


Culture













2


Gram stain













3


NAAT













4


Nucleic acid probe













5


Test not specified














47 Trichomonas Tests

(T. vaginalis tests)

Result

Site of Specimen Collection (select one for each test performed)

Pos(+)

Neg(-)

Indeterminate

Anorectal

Cervical

Lymph node

Ocular

Pharyngeal

Urethral (swab)

Urine

NOS


1


Culture













2


EIA / other molecular assay













3


Wet mount













4


Test not specified













*DFA = Direct fluorescent amplification

EIA (ELISA) = Enzyme-linked immunoassay

NAAT = Nucleic acid amplification test (usually done on urine specimen, sometimes on cervical /urethral swabs)

Nucleic acid probe – Also known as DNA probe assay, direct hybridization probe test


INFECTIOUS DISEASE TESTS: Drug Resistance



Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


48 Resistance test

for INH (TB drug)







49 Resistance test

for Rifampicin

(TB drug)







50 Genotypic ART resistance test (Select one below)



Select all ART classes documented with resistance and/or possible resistance:



1 Resistance reported

FI PI NRTI NNRTI ART classes not specified



2 Possible resistance reported

FI PI NRTI NNRTI ART classes not specified



3 No resistance reported




4 Indeterminate result




5 Test result not documented



6 Documented that genotypic resistance testing was not done



7 Genotypic resistance testing not documented


51 Phenotypic ART resistance test (Select one below)


Select all ART classes documented with resistance and/or intermediate resistance:



1 Resistance reported

FI PI NRTI NNRTI ART classes not specified



2 Intermediate resistance reported

FI PI NRTI NNRTI ART classes not specified



3 No resistance reported




4 Indeterminate result




5 Test result not documented



6 Documented that genotypic resistance testing was not done



7 Phenotypic resistance testing not documented


XI. LABORATORY TESTING – OTHER TESTS cont’d


52 Virtual phenotypic ART resistance test (Select one below)




Select all ART classes documented with resistance and/or possible / intermediate resistance:



1 Resistance reported

FI PI NRTI NNRTI ART classes not specified



2 Possible/intermediate resistance reported

FI PI NRTI NNRTI ART classes not specified



3 No resistance reported




4 Indeterminate result




5 Test result not documented



6 Documented that genotypic resistance testing was not done



7 Virtual phenotypic resistance testing not documented




OPTIONAL - FOR LOCAL USE ONLY

M MP SPVF v3.0.0

Abstraction

MMP Participant ID: Facility ID:

(ID of the facility where abstraction is being conducted)







Date of Visit:


XII. REMARKS













































Page 22 of 22

OMB 0920-0740 - Surveillance Period Visit Form - 6/2010

File Typeapplication/msword
File TitleMedical monitoring project (MMP)
AuthorRita Morgan
Last Modified Byziy6
File Modified2009-02-26
File Created2009-02-26

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