KBP5074-2-001 Prescreening Survey

KBP5074-2-001 Screening and Prescreening Survey

The purpose of this survey is to determine if your site has any patients that could be potentially eligible for screening in the upcoming week. Please know that this survey will come to your site on a weekly basis for completion.

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* 1. Principle Investigator Name

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* 2. Site Number

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* 3. Name of Person Completing the Questionnaire

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* 4. Date of Survey Completion

Date / Time

Date

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* 5. Did your site prescreen any subjects this week?

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* 6. Date of prescreening of patient

Date / Time

Date

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* 7. Initials of Prescreened Patient

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* 8. Did the Subject Meet Inclusion Criteria

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* 9. If No, Which primary exclusion criteria did they meet?

Other (please specify)

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* 10. If Yes, what is the potential screening date?

Date / Time

Date

KBP5074-2-001 Prescreening Survey

KBP5074-2-001 Screening and Prescreening Survey

Question Title

* 1. Principle Investigator Name

Question Title

* 2. Site Number

Question Title

* 3. Name of Person Completing the Questionnaire

Question Title

* 4. Date of Survey Completion

Question Title

* 5. Did your site prescreen any subjects this week?

Question Title

* 6. Date of prescreening of patient

Question Title

* 7. Initials of Prescreened Patient

Question Title

* 8. Did the Subject Meet Inclusion Criteria

Question Title

* 9. If No, Which primary exclusion criteria did they meet?

Question Title

* 10. If Yes, what is the potential screening date?

Question Title

* 11. Other