Form 3 Attachment 4 Form 2a Eligibility Checklist

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 OMB Number 0925‐XXXX 
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Exp. Date: XX/XX/XXX 
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Study ID: __ __ __ __ __ __ __ __ __ __
CEIRS Human Influenza Surveillance Study
Form 2A: Eligibility Checklist
Inclusion Criteria
Symptomatic Influenza Indeterminate
Subjects require YES to all three questions to be eligible for Symptomatic Subject

□ No

1.

Is the subject 18 years old or older

2.

In the past 7 days, has the subject experienced any fever (needs one):

□ No
□ No

a. Documented fever (≥38°C)
b. Report of fever
3.

□ Yes
□ Yes
□ Yes

In the past 7 days, has the subject experienced any of the following symptoms (needs one):

□ No
□ No
□ No

a. Cough
b. Headache
c.

Sore throat

□ Yes
□ Yes
□ Yes

Asymptomatic Influenza Indeterminate
Subjects require YES to Question 1 and NO to all in Question 2 be eligible as Asymptomatic Subject

□ No

□ Yes

1.

Is the subject 18 years old or older

2.

In the past 7 days, has the subject experienced any of the following symptoms:

□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No

a. Documented fever (≥38°C)
b. Report of fever
c. Cough
d. Headache
e. Sore throat
f. Myalgia
g. Rhinorrhea / nasal congestion
h. Shortness of breath

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

Influenza Positive
Subjects require YES to both questions be eligible as Influenza Positive Subject.
1.

Is the subject 18 years old or older

□ No

□ Yes

2.

Has the subject tested positive for influenza test this visit?

□ No

□ Yes

Page 1 of 2

Form 2A: Eligibility Checklist

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
Exclusion Criteria
All subjects require NO for each question to be eligible.

□ No
□ No
□ No
□ No
□ No

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

Is the subject eligible as a Symptomatic Subject?

□ No

□ Yes

Is the subject eligible as an Asymptomatic Subject?

□ No

□ Yes

Is this subject eligible as an Influenza Positive Subject?

□ No

□ Yes

□ No

□ Yes

1.

Unable to write or speak English

2.

Unable to provide informed consent

3.

Unable to provide telephone number for follow-up

4.

Currently incarcerated

5.

Previously enrolled in this study

Eligibility

Consent
Did the subject complete the written consent form?

Page 2 of 2

Form 2A: Eligibility Checklist

Version 2.0
01/05/2015