(pre) Screening Log

Principal Investigator:

HRC Protocol #:

Study Title:

Sponsor:

* Subject	Date

Screened	Met Eligibility

Criteria	Reason for Exclusion/Screen Failure	For Subjects Eligible and Signing Consent
Date of Consent	Subject Study #
1	Y	N
2	Y	N
3	Y	N
4	Y	N
5	Y	N
6	Y	N
7	Y	N
8	Y	N
9	Y	N
10	Y	N
11	Y	N
12	Y	N
13	Y	N
14	Y	N
15	Y	N

* Use a pre-screening number, initials, or first name to identify subjects at pre-screening, to be HIPAA compliant, see “Pre-Screening of Subjects” HRC

guidance document: http://healthcare.partners.org/phsirb/prescreen.htm

Human Research Quality Improvement Program

Partners HealthCare System, Inc. All Rights Reserved 2004

Screen/Enrollment Log

Information Systems

2014-05-15

Partners Information Systems

Partners HealthCare System