Cx3 Study - Patient Enrollment Form

F

Study barcode ID

orm Approved

OMB No. 0920-xxxx

Exp. xx/xx/xxxx

CDC CERVICAL CANCER STUDY (Cx3 Study)

Patient Enrollment Form – [CLINIC NAME]

First Name: ­­­­­­­­­­­­_____________________ Last Name: ____________________________

Date of Birth:

month year

Provider: 1=[Provider1] 3=[Provider3] 5=[Provider5] 7=[Provider7]

(circle) 2=[Provider2] 4=[Provider4] 6=[Provider6] 8=[Provider8]

Clinic’s Patient ID number: _________________

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Selected for Patient Survey: Yes / No Consented to Patient Survey: Yes / No

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If patient consented to participate in the Patient Survey complete the following section:

PATIENT CONTACT INFORMATION:

Address: ________________________________________________________

________________________________________________________

Phone numbers: Home: _______ —_______ —_______

Work: _______ —_______ —_______ Cell: _______ —_______ —_______

Name and address of a friend or family member who will always know where to contact patient, in case she has moved and we are having trouble contacting her.

Name of Friend or Relative: ­­­­­­­­­­­­______________________________

Telephone Number of Friend or Relative: ­­­­­­­­­­­­_______ —_______ —_______

Type of phone (circle): Home / Work / Cell

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)