12a Subject Checklist

Study ID: __ __ __ __ __ __ __ __ __ __
Visit __ of __
CEIRS Human Influenza Surveillance Study
Form 12A: Subject Checklist
Instructions: Research Coordinator is to initial where he or she successfully completes a task listed below
Enrollment:
___ Meets Eligibility Criteria (Form 2A: Eligibility Checklist)

□ Quality Control check of 100% of Inclusion and Exclusion Criteria
___ Written Consent Obtained
___ Form 4A: Demographic Information
___ Form 5A: Current Symptoms
___ Form 6A: Medical History
___ Form 7A: Sample Collection
___ Subject compensated $50
___ Enter data into REDCap
___ Quality control check of enrollment data entered
Follow up:
___ Form 8A: Follow-up phone call/visit
___ Form 8A: Blood (Serum) Sample Collected
___ Subject compensated $75 (initial if applicable)
___ Form 9A: Chart Review: ED Visits
___ Form 10A: Chart Review: Inpatient Hospitalization
___ All data into REDCap
___ Quality control check of follow up data entered
Other:
___ Quality assurance 10% check of all data (source documents and REDCap) (initial if applicable)

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Form 12A: Subject Checklist

Version 2.0
01/05/2015