Universal ID
Houshold #
Household member
DataFax Study Number
DataFax Plate Number
Visit Code
Enrollment Date(mm)
Enrollment Date(dd)
Enrollment Date(yy)
Enrollment Date
Staff ID
Team ID
1.Elig for S-T Cohort?
1a.Primary reason-inelig.
1a. Referral #
1a. No referral
1a. Other, specify text
2. Enroll in S-T Cohort?
2a. Prim reason not enrol
2a. Other, specify text