3a Subject Identification

Study ID: __ __ __ __ __ __ __ __ __ __
CEIRS Human Influenza Surveillance Study
Form 3A: Subject Identification and Contact Information

KEEP SEPARATE FROM REMAINDER OF FORMS
DO NOT ENTER INTO REDCap DATABASE
Subject Identification:
Medical Record Number: ________________________
Name:
(First Name)

(Middle Name)

(Last Name)

Date of birth: __ __/ __ __/ __ __ __ __ (mm/dd/yyyy)

Contact Information:

Contact Telephone**:

(

)

(Home/ Work/Cell)

Alternate Telephone 1:

(

)

(Home/ Work/Cell)

Alternate Telephone 2

(

)

(Home/ Work/Cell)

Alternate Telephone 3:

(

)

(Home/ Work/Cell)

**Please Note: At least one telephone number is required, with at least two contact numbers strongly suggested.

Subject has provided permission to leave messages:
Permission to leave message with someone else:

□ No
□ No

□ Yes
□ Yes

Follow-Up Appointment:
Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Time: __ __ : __ __ (24-hour clock)

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Form 3A: Subject ID

Version 2.0
01/05/2015