ࡱ> 02/{ bjbjBrBr 4  =o80$TzpppppJ       $DDpp4YLpppW9f o0MfMMXDDfLM : Subject Contact Log Trial Name: ___________________________________ Subject #: Attempt to call all subject-provided phone numbers at least 3 times. 1st Attempt: Phone #: _______________________________ Date Called: Notes: 2nd Attempt: Phone #: _______________________________ Date Called: Notes: 3rd Attempt: Phone #: _______________________________ Date Called: Notes: Other numbers called: Notes: Send certified letters if phone attempts do not work. Attach copies of letters and receipts or returned envelopes to this form. ( Certified letter sent: _______________ Result: ( Certified letter sent: _______________ Result: ( Certified letter sent: _______________ Result: Contact all primary physicians that may have information on this subject. ( Physician: __________________________________________ Date Contacted: Result: ( Physician: __________________________________________ Date Contacted: Result: ( Physician: __________________________________________ Date Contacted: Result: Check in [list resource, e.g., local papers obituaries, online resources]. ( [resource 1] date: _______________ Result: ( [resource 1] date: _______________ Result: ( [resource 2] date: _______________ Result: ( [resource 2] date: _______________ Result: ( [resource 3] date: _______________ Result: ( [resource 3] date: _______________ Result: File with the subjects CRF. Attempt to contact subject again at the end of the study. Date subject was lost to follow-up: _______________ (All attempts failed and study has ended.)     This template is made available by CTN Best Practices and can be found at ctnbestpractices.org. $5CEPQRfw, - 7 8 } ~ , - . 9 : _ ` a b m n ĸĸĸĸĸĸĸĸĸĊ~Ēss~h=hhRCJaJhhRhhR>*CJaJhhRCJaJ jqhhRCJaJhhR5\]h=5\]hw-hw-5\]h=hw->*CJaJh=hw-CJaJh5\]hhw-5\]hh>*hhw-hhw-6>*CJ aJ -R. 9  - a  ^ i `'@BxgdhR `'BxgdhR `'xgdw- `'xgdw- `'xgdw-xgdy `'Bxgd $a$gdy     % > @ C \ ] g h i j {      _ a b c o ָָ˰˥h qh q>*CJaJh qCJaJ jqh qCJaJh q5\]h=hw-CJaJhhR5\]h=hw-5\]hhRhhR>*CJaJhhRCJaJ jqhhRCJaJh=hhRCJaJ4i  a ! Q =?@BCEFHIxgd `'xgd qxgdy `'@BxgdhR `'BxgdhR    ! " # / F G O Q R S _ v w  9:<վվվվվվվվվվկhy5CJ\]aJh=hw-5CJ\]aJh=hw-CJaJh qh q>*CJaJh qCJaJh=h qCJaJ jqh qCJaJh qhw->*CJaJ<<=>@ACDFGIh qh qCJOJQJaJhh qCJOJQJaJhtjhtUh=hw-CJaJIxgd$a$gd21h:p=/ =!8"8#8$% ^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH N@N  Heading 1$$@&a$56>*CJ \]H@H  Heading 2$@&56>*CJ\]DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 4@4 Header  !4 4 Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  nnnnnq < i I @ @H 0(  0(  B S  ? OLE_LINK1 OLE_LINK2 _Hlk199120159III<=?@BCEFHI<=?@BCEFHI#o y{w%M)`p6hRpeok qEXmt=w-=?@@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial;WingdingsE. Century GothicA$BCambria Math"hI2 GI2 GCFO O !8824::2QHX(?2!xx Subject Contact LogCrystal Gruetzmacherlori1Oh+'0d    , 8DLT\Subject Contact LogCrystal Gruetzmacher Normal.dotmlori12Microsoft Office Word@@ȈR@-9@-9O՜.+,0  hp  The Heart Doctors : Subject Contact Log Title  !"#$%&()*+,-.1Root Entry Fb931TableMWordDocument4SummaryInformation(DocumentSummaryInformation8'CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q