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:
  1. ___/___/____

  1. ___/___/____

  1. ___/___/____

  1. ___/___/____
/ After 4 attempts to contact participant will no longer be contacted for possible participation in this study.
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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