Universal ID
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. Other, specify text
2. Enroll in Cohort C?
2a. Prim reason no enroll
2a. other, specify text
Staff Signature / Date