Eligibility Checklist

Subject ID #: __________Date:_________

Inclusion Criteria (circle ‘Yes’ or ‘No’)

(All items must be marked ‘Yes’ for the subject to be eligible)

Complete fields with criteria from approved protocol, adding lines as needed.

1.	Yes	No
2.	Yes	No
3.	Yes	No
4.	Yes	No

Exclusion Criteria (circle ‘Yes’ or ‘No’)

(All items must be marked ‘No’ for the subject to be eligible)

Complete fields with criteria from approved protocol, adding lines as needed.

1.	Yes	No
2.	Yes	No
3.	Yes	No
4.	Yes	No

The subject is:

☐           Eligible for the study

☐           Not eligible for the study

CRF completed by:      Date:

PI Signature:        Date: