Form 2 Attachment 3 Form 1a Screening and Enrollment Log

Form Approved  
               OMB Number 0925‐XXXX 
Exp. Date: XX/XX/XXX 

Public reporting burden for this entire collection of information packet is estimated to average 60 minutes per response, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892‐7974, ATTN: PRA (0925‐XXXX). Do not return the completed form 
to this address. 

CEIRS Human Influenza Surveillance Study
Form 1A: Screening and Enrollment Log Active Surveillance

To be maintained by Study Centers and made available upon request.
The following table will be distributed in a Microsoft Excel format for use at individual medical centers; It is housed in a secure folder.
Row 1 represents column headings
Row 2: represents options available on a drop-down menu.

Date

Shift

Mm/dd/yyyy

Sex

Ethnicity

Age

Morning
Evening

Male
Female

Hispanic or
Latino

Non-Hispanic or
Non-Latino

Eligible
Symptomatic
Surveillance

Race/ Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
Islander
White
Other

Eligible
Asymptomatic
Surveillance

Yes
No

Eligible
Influenza
Positive

Yes
No

Yes
No

Enrolled?

Reason if not Enrolled

Yes
No

Declined

Left ED prior to enrollment
Did not like the idea of participating in a study.
Does not meet inclusion criteria
Felt too sick to be in the study
Doesn't speak/read English
Lack of Adequate Compensation.
Unable to consent
Did not want to receive a nasal swab.
No contact information
Did not want to return for Follow-Up
Currently incarcerated
Other
Previously Enrolled
Other

If enrolled,
Completed?

Reason if subject declined enrollment

Yes
No

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Form 1A: Screening and Enrollment Log Active Surveillance

Version 2.0
01/05/2015