Form 12 Attachment 5 Form 3a Subject Indentification

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. 
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