Potential Participant Review Form

Part I. Please provide the following information for each potential participant review.

Date Review Initiated (mm/dd/yyyy):
Name:
Hospital Number:
Age:
Gender: Male Female
Race:
Ethnicity (Spanish/Hispanic Origin):
Language spoken:
Medicare?:
Disease Type/Site:
IRB Number:
Protocol Type:
  Specify Other:
Protocol Sponsor:
  Specify Other:
Physician:
  Specify Other:
Conference/Clinic:
  Specify Other:
Review Outcome: a. Initial review excludes patient
b. Initial review does not exclude patient
If a, Reason for exclusion:

Part II. Please complete if patient screened for protocol.

 

Screening Outcome: Enrolled (please submit Enrollment Form)
Not enrolled because:
  Please explain:
Comments:
Name of person completing form:
E-mail address:
 
Primary teaching affiliate
of BU School of Medicine