Phone Screen Checklist
Participant’s Initials______HRPO#:
Participant’s Name: ______Initials: ______
Contact Information:
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Phone Screen Checklist
Participant’s Initials______HRPO#:
□Home:______
□Work:______
□Cell:______
□Other:______
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Phone Screen Checklist
Participant’s Initials______HRPO#:
Attempts to contact: / Comments: / Signature & Date of PI/Designee:- ___/___/____
- ___/___/____
- ___/___/____
- ___/___/____
Phone Script
Hello, my name is______], from Washington University in St. Louis-School of Medicine.
How are you? [Await response]
I received your name and telephone number from (Dr. ______). I am calling you about a research study because you have been diagnosed with [insert reason here per phone script].
Would you be interested in learning more about the study? You are free to ask any questions at any time.
Yes
No-If No, summarize reason for declining below, thank them for their time and hang up:
(Insert Phone Script Here)
Do you think you may be interested in participating in this phone screen? Yes No
If Yes, precede to the criteria checklist questions.
If no, summarize the reason for declining, thank them for their time:
Do you have any questions? Yes No
If Yes, summarize below:
______/______/______
PI/Designee Signature Date
Criteria Checklist:
□What is the best phone number to contact you at?(______)______-______or (______)______-______
□Can we email or mail you a copy of the consent form to review prior to your screening visit?
□Email ______@______
□Mail (Address): / □Yes
□No
□What is your date of birth? _____/_____/______
□
□ / Yes
No
□ / Yes
No
□ / Yes
No
□ / Yes
No
□ / Yes
No
□ / Yes
No
~Thank them for taking time to complete the phone screen and proceed to the appointment checklist~
______/______/______
PI/Designee Signature Date
Appointment Checklist
□Please allow for ______[time length]for your In-Person Screening Visit.
□Appointment will start at ______[location].
□You will review the consent(s) form with our Clinical staff, they will review your options and answer any questions you may have.
□You may have all or some of the following exams:
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Phone Screen Checklist
Participant’s Initials______HRPO#:
- [Insert study procedures]
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Phone Screen Checklist
Participant’s Initials______HRPO#:
□[List any pre-visit instructions for participants]
.
Confirm:
□Screening date & time: M T W TH F _____/_____/______@ ______:______am/pm
□Verified Directions
□Verified Telephone Contact Information for Unit (quote 8 to 4:30 as best time to call)
□Verified all above information with subject on:
- _____/_____/______By: ______
(Signature)
Additional Comments:
______
______/______/______
PI/Designee Signature Date
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