Form 10 Attachment 3 Form 1a Screening and Enrollment Log

Form Approved  
 OMB Number 0925‐XXXX 
Exp. Date: XX/XX/XXX 
Public reporting burden for this form is estimated to average 10 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

Mm/dd/yyyy

Page 1 of 1

Shift

Age

Morning
Evening

Sex

Male
Female

Ethnicity

Hispanic or
Latino
Non-Hispanic or
Non-Latino

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

Eligible
Symptomatic
Surveillance

Eligible
Asymptomatic
Surveillance

Eligible
Influenza
Positive

Yes
No

Yes
No

Yes
No

Enrolled?

Reason if not Enrolled

Reason if subject declined enrollment

Yes
No

Declined
Left ED prior to enrollment
Does not meet inclusion criteria
Doesn't speak/read English
Unable to consent
No contact information
Currently incarcerated
Previously Enrolled
Other

Did not like the idea of participating in a study.
Felt too sick to be in the study
Lack of Adequate Compensation.
Did not want to receive a nasal swab.
Did not want to return for Follow-Up
Other

Form 1A: Screening and Enrollment Log Active Surveillance

If enrolled,
Completed?

Yes
No

Version 2.0
01/05/2015