Form 33 Attachment 17 Form15a QC 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.

CEIRS Human Influenza Surveillance Study Form 15A: QC Checklist

The following table will be distributed in a Microsoft Excel format for use at individual medical centers; It is housed in a secure folder.

Study ID

Form 2A: Eligibility

RedCap

QC

Form 4A: Demographics

RedCap

QC

Form 5A: Current Symptoms

RedCap

QC

Form 6A: Medical History

RedCap

QC

JHH001

RM

RM

AD

RM

RM

AD

RM

RM

AD

RM

RM

AD

Form 7A: Sample Collection	RedCap	QC	Form 8A: Follow Up	RedCap	QC	Form 9A: Chart Review ED	RedCap	QC	Form 10A: Chart Review hospitalization	RedCap	QC
RM	RM	AD	RM	RM	AD	RM	RM	AD	RM	RM	AD

Page 1 of 1 Form 15A: QC Checklist Version 2.0 01/05/2015