Form 31 Attachment 15 Form 13a Enrollment Report

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 13A: Enrollment Report

Instructions: To be completed every other week during Clinical Study

Site: _ Date:

Person Completing this Form:

Enrollment Dates Included: Start:

End:

Number of patients Screened:

Number of patients Eligible:

Number of patients Enrolled:

Why were patients not enrolled?

Number of Patients	Reason Not Enrolled
	Did not meet inclusion/exclusion criteria
	Declined: Did not like the idea of participating in a study.
	Declined: Felt too sick to be in the study
	Declined: Lack of Adequate Compensation
	Declined: Did not want to receive a second nasal swab
	Declined: Did not want to return for Follow-Up
	Declined: Other
	Left ED prior to enrollment
	Other

Inclusion Criteria Check

Number of Patients	Eligibility Criteria
	All inclusion criteria met (documented)
	Met none of the exclusion criteria (documented)
	Inclusion and Exclusion criteria checked (100%)

Number of patients Withdrawn:

Page 1 of 1 Form 13A: Enrollment Report Version 2.0 01/05/2015