Form 30 Attachment 14 Form 12a Subject Checklist

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.

Study ID:

CEIRS Human Influenza Surveillance Study Form 12A: Subject Checklist

Visit of

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)

Page 1 of 1 Form 12A: Subject Checklist Version 2.0 01/05/2015