13a Enrollment Report

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
Reason Not Enrolled
Patients
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
Eligibility Criteria
Patients
All inclusion criteria met (documented)
Met none of the exclusion criteria (documented)
Inclusion and Exclusion criteria checked (100%)

Number of patients Withdrawn: __________

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Form 13A: Enrollment Report

Version 2.0
01/05/2015