ࡱ> npm[ bjbjmm ;lbbDDD$$$8\D4$+ `4444|T@$#!#"44R8444׀HR0+ _$8_$_$|&+ _$DB :  STUDY VISIT CHECKLIST Ensure consistency and documentation of study visits.  SUBJECT ID: DOB: INFORMED CONSENT FORMCHECKBOX  PI/Authorized Staff Explained StudyPI/Staff: FORMCHECKBOX  Copy of consent given to adult subject and/or LAR; child subject and/or Parent or Legal Guardian FORMCHECKBOX  Adult Subject and/or LAR; Child Subject and/or Parent or Legal Guardian- Signed ConsentDate Signed:Is Consent Valid? FORMCHECKBOX  YES  FORMCHECKBOX  NO FORMCHECKBOX  If subject did not sign consent, explain:STUDY VISITS **Please customize this form to meet the visit requirements of your specific study.Study Visit 1:Date Completed:PI/Staff InitialsIf subject did not complete test or completed test on different date, please explain: FORMCHECKBOX  e.g. Complete Blood Count FORMCHECKBOX  e.g. Pulmonary Function Test FORMCHECKBOX  e.g. EKG FORMCHECKBOX  e.g. Chest x-ray FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   Study Visit 2:Date Completed:PI/Staff InitialsIf subject did not complete test or completed test on different date, please explain: FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   Study Completion:If subject did not complete study, please explain: FORMCHECKBOX  Subject Completed StudyDate Completed: FORMCHECKBOX  If applicable, study reimbursementDate Given: NOTES:     Page _____ of _____ Principal Investigator: ____________________ IRB#: ______________________ Sponsor: _________________________ Study Title: _______________________________________________________________________________________________ NOPQ\]npqrüӓ}ndZKZ9KZK"jhMB*CJUphjhMB*CJUphhMB*CJphhMB*CJphhMh B*CJaJphh>5B*\phh 5B*\ph hMhc9CJOJQJ^JaJ.jhc9CJOJQJU^JaJmHnHu hc9hc9h~ hc9h>hc95hc9CJOJQJ^JaJhMCJOJQJ^JaJ hqhMCJOJQJ^JaJPRSTUVWXYZ[\]qr$If  !&dP  gdc9gdc9$a$gd>gdM TPX 2@@@@L`LgdM> rg x$Ifgd{kd$$IflrH%9H964 lalx$If     % = ? @ N O P g j ʶԶo]"j hMB*CJUph"jhMB*CJUphhMB*CJphjhMB*CJUphhhB*CJph"j"hMB*CJUphh{B*CJphhr9TB*CJphh]_B*CJphjhMB*CJUph"jhMB*CJUphhMB*CJph$> ? zzjzx$If^`x$If x$Ifgd{rkdw$$Ifl\H9H964 lal 4 5 6 zrr&Lkd$$Ifl0H9H`'964 lalx$Ifkd~$$IflrH%9H964 lal   6 ; < H J K O Q , - ; < = X \ ] k {i\Gi\i\(jbhN`hN`B*CJUph_IzhN`hN`B*CJph_Iz"jhN`hN`B*CJUph_Izh>hN`5B*CJphhN`hN`5B*CJph_IzhN`5B*CJph_IzhN`B*CJphhN`5B*\phhM5B*\phhMhMB*CJaJphjhMB*CJUph"j7hMB*CJUphhMB*CJph6 7 8 9 : ; < J K L M N pe x$IfgdN`kd$$Ifl_rH%9H964 lalx$If N O zr3( x$Ifgd XK?kdx$$Ifl499964 lalf4yt XKx$Ifkd$$IflrH%9H964 lal + , X Y Z [ wwwwx$Ifukd$$Ifl4\l9T<964 lalf4 x$Ifgd XK[ \ x$Ifukd$$Ifl4\l9T<964 lalf4k l m        ̭̘‰w‰e‰S‰"jJ hN`B*CJUph"jM hN`B*CJUph"jP hN`B*CJUphjhN`B*CJUph(jS hN`hN`B*CJUph_Iz(jX hN`hN`B*CJUph_IzhN`B*CJphhN`hN`B*CJph_Iz"jhN`hN`B*CJUph_Iz(j]hN`hN`B*CJUph_Iz x$Ifukd$$Ifl4\l9T<964 lalf4 x$Ifukd $$Ifl4\l9T<964 lalf4 x$Ifukd $$Ifl4\l9T<964 lalf4   x$Ifukd $$Ifl4\l9T<964 lalf4      x$Ifukd $$Ifl4\l9T<964 lalf4  - . / 0 wwwx$If x$IfgdXukd $$Ifl4\l9T<964 lalf4 ) * + 1 2 @ A B H I W X Y _ ` a p       & n\"jhc9B*CJUph"jhc9B*CJUphjhc9B*CJUphhc9B*CJphh>hc95B*CJphhc9hM"j?hN`B*CJUph"jBhN`B*CJUphjhN`B*CJUph"jGhN`B*CJUphhN`B*CJph0 1 D E F G wwwx$If x$IfgdXukd$$Ifl4\l9T<964 lalf4G H [ \ ] ^ wwwx$If x$IfgdXukd$$Ifl4\l9T<964 lalf4^ _ ` a p }}}} x$Ifgdc9ukd$$Ifl4\l9T<964 lalf4 |||| x$Ifgdc9xkd<$$Ifl4\l9T<964 lalf4ytc9     |||| x$Ifgdc9xkd=$$Ifl4\l9T<964 lalf4ytc9  * + , - |||| x$Ifgdc9xkd>$$l4ı9<964 lalf4ytc9& ' ( . / = > ? E F T U V \ ] k l m s t ձ՟Ս{i"jhc9B*CJUph"jhc9B*CJUph"jhc9B*CJUph"jhc9B*CJUph"jhc9B*CJUph"jhc9B*CJUphhc9B*CJphjhc9B*CJUph"jhc9B*CJUph#- . A B C D |||| x$Ifgdc9xkd?$$Ifl4\l9T<964 lalf4ytc9D E X Y Z [ |||| x$Ifgdc9xkdB$$Ifl4\l9T<964 lalf4ytc9[ \ o p q r |||| x$Ifgdc9xkdE$$Ifl4\l9T<964 lalf4ytc9r s |||| x$Ifgdc9xkdH$$Ifl4\l9T<964 lalf4ytc9 |||| x$Ifgdc9xkdK$$Ifl4\l9T<964 lalf4ytc9 |||| x$Ifgdc9xkdL$$Ifl4\l9T<964 lalf4ytc9 |||| x$Ifgdc9xkdO$$Ifl4\l9T<964 lalf4ytc9 /0>?@lm{|}տsiaYNhc9hc9B*phhMB*phh B*phh B*CJph"jhMB*CJUph"jhMB*CJUphjhMB*CJUphhMB*CJphh>hM5B*CJphhc9"jhc9B*CJUphhc9B*CJphjhc9B*CJUph"jhc9B*CJUph |||| x$Ifgdc9xkdR$$Ifl4\l9T<964 lalf4ytc9 .}}}}x$IfxkdU$$Ifl4\l9T<964 lalf4ytc9./Yijkx$Ifukd$$Ifl4\H9H964 lalf4klx$Ifukd$$Ifl4\HP9H964 lalf4x$IfukdL$$Ifl4\HP9H964 lalf4x$Ifukd $$Ifl4\HP9H964 lalf4I9kd!$$Ifl99964 lal$Ifukd $$Ifl4\HP9H964 lalf4v;;kd"$$Ifl99964 lald$If^d`gdM9kd7"$$Ifl99964 lal$If9kd!$$Ifl99964 lalN9kd#$$Ifl99964 lal9kd@#$$Ifl99964 lal$If9kd"$$Ifl99964 lalECC<kd$$$Ifl99964 lalytc9<kdE$$$Ifl99964 lalytc9 $Ifgdc99kd#$$Ifl99964 lal4JM[ƴƛ hTu|hc9 hg(5 hc95hTu|hc95hc9)h2thc9B*CJOJQJ^JaJph333#hc9B*CJOJQJ^JaJph333hijhiUh B*phhc9OJQJ^Jhc9hc9B*ph h)ghc9CJ$OJQJ^JaJ$gdc9 !81^gdM9&P1h0:pM= /!"#h$% $$Ifl!vh#vH#v#v#v#v:V l965H5555/ 4altDeCheck1tDeCheck5$$Ifl!vh#vH#v#v#v:V l965H555/ /  / / 4altDeCheck2tDeCheck3tDeCheck4$$Ifl!vh#vH#v#v#v#v:V l965H5555/ / /  / 4altDeCheck6q$$Ifl!vh#vH#v`':V l965H5`'/ /  4al$$Ifl!vh#vH#v#v#v#v:V l_965H5555/ / /  / / 4al$$Ifl!vh#vH#v#v#v#v:V l965H5555/ 4ala$$Ifl!vh#v9:V l49659/ 4alf4yt XK$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4tDeCheck7$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4tDeCheck8$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4tDeCheck9$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4vDeCheck10$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4vDeCheck11$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4vDeCheck12$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4vDeCheck13$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4tDeCheck9$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4vDeCheck10$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4vDeCheck11$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9tDeCheck7$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9tDeCheck8$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9tDeCheck9$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9vDeCheck10$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9vDeCheck11$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9vDeCheck12$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9vDeCheck13$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9tDeCheck9$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9vDeCheck10$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9vDeCheck11$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9vDeCheck12$$Ifl!vh#v#v#vT#v<:V l496555T5</ 4alf4ytc9$$Ifl!vh#vH#v#v#v:V l4965H555/ / / / / 4alf4vDeCheck21$$Ifl!vh#vH#v#v#v:V l4965H555/ / / / / 4alf4vDeCheck20$$Ifl!vh#vH#v#v#v:V l4965H555/ / / / / 4alf4$$Ifl!vh#vH#v#v#v:V l4965H555/ / / / / 4alf4$$Ifl!vh#vH#v#v#v:V l4965H555/ / / / / 4alf4U$$Ifl!vh#v9:V l9659/ 4alU$$Ifl!vh#v9:V l9659/ 4alU$$Ifl!vh#v9:V l9659/ 4alY$$Ifl!vh#v9:V l9659/ 4alU$$Ifl!vh#v9:V l9659/ 4alU$$Ifl!vh#v9:V l9659/ 4alU$$Ifl!vh#v9:V l9659/ 4alU$$Ifl!vh#v9:V l9659/ 4al[$$Ifl!vh#v9:V l9659/ 4alytc9[$$Ifl!vh#v9:V l9659/ 4alytc9s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH J`J Normal!B*CJ_HaJmH phMMMsH tH B@B  Heading 1 $x@& 5CJ\DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4@4 MHeader  !4 @4 MFooter  !jj M Table Grid7:V0PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< <l CCCF k  &  !)4> 6 N [   0 G ^  - D [ r .k  "#$%&'(*+,-./01235?O,<\l*1AHX'.>EU\ls/?l|G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$@ @H 0(  (  b  # 3"? B S  ?Pl86 tCheck1Check5Check2Check3Check4Check6Check7Check8Check9Check10Check11Check12Check13Check21Check20@-]0m P =m@}NO=RX_OQ__NO=RX_OQ__MC ~ X_Qy&g(o+c9 XKp&Qr9T]_N`6xm6X> Vhi `{<@@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialA$BCambria Math"hWGWGw+&  !hr43qHP?p&Q2!xxMb SUBJECT VISIT CHECKLIST:ch108327Prachniak, KimOh+'0  < H T `lt|SUBJECT VISIT CHECKLIST: ch108327NormalPrachniak, Kim4Microsoft Office Word@ @~?@^@k,՜.+,0 hp  Children's Hospital, Boston  SUBJECT VISIT CHECKLIST: Title  !"#$%&'()*+,-./012345689:;<=>?@ABCDEFGHIKLMNOPQRSTUVWXYZ[\^_`abcdfghijkloRoot Entry F`yHqData 7$1TableJ_$WordDocument;lSummaryInformation(]DocumentSummaryInformation8eCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q