Continued Follow-up Request Form
Date of Request:
*
-
Month
-
Day
Year
Date
Coordinator Name
*
First Name
Last Name
Coordinator Email:
*
Site Name:
*
Site Number
*
KID
*
Date of Visit
-
Month
-
Day
Year
Date can be scheduled or tentative
Select the current Protocol Amendment that is approved at site:
*
May 2022
December 2020
PIP survey
Method to complete participant survey:
*
PFU01 form (paper or PDF)
ePIP online survey
Language of Survey:
English
Spanish
Behavioral Questionnaire
The May 2022 Amendment stipulates that an electronic BRIEF behavioral assessment should be administered to individuals participating in the Continued Follow-up (PIP/ePIP) Protocol.
There is no Spanish version of the Behavioral Questionnaire. Please confirm the participant/family will be able to complete the questionnaire in English.
*
Yes, can complete English questionnaire
No, unable to complete English questionnaire
Study Coordinator Contact Information
Has the coordinator contact information changed since the last request?
*
Yes
No
Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Comments
ckidship
Submit
Should be Empty: