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OPT Form 97 V1 (1-1) MAR 06

II. attach PID label here. -. -. Patient ID:. -. -. Month. Day. Year. Clinical Unit:. Visit Date:. Coordinator Code:. . Visit:. Instructions: To be completed by the Enrollment Site Study Coordinator.

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OPT Form 97 V1 (1-1) MAR 06

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  1. II attach PID label here - - Patient ID: - - Month Day Year Clinical Unit: Visit Date: Coordinator Code:  Visit: Instructions: To be completed by the Enrollment Site Study Coordinator. Complete this form after study visits 1 and 2.  1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Visit 1 Visit 2 2 2 2 2 2 2 2 2 2 2 2 2 2 No No No No No No No No No No No No, explain: ______________________________________________________ No Physical & Laboratory (Form 94) Child Medical History (Form 95) Parent/Caregiver Demographics (Form 96) Child History (Form 92) Life Style History (Form 93) Raven SPM PLS IV BSID III Home Scale (Form 91) Child History (Form 92) Physical & Laboratory (Form 94) BSID III Parent/Caregiver Demographics (Form 96) PLS IV Peabody Development Motor Scale Life Style History (Form 93) Home Scale (Form 91) 1 The subject’s whereabouts are unknown 2 The subject has moved to a different geographical area and cannot attend the visit 3 The subject has withdrawn consent for study participation 4 The subject is not interested and does not wish to attend this visit 5 Other, specify: _____________________________________________________________________ STOP. The form is complete. 5. Why did the subject miss the visit? CONFIRMATION OF STUDY VISIT / REPORT OF MISSED VISIT 1. Did the subject attend the visit? 2. List assessment tools completed at this visit: 3. Did the child score more than 1.5 standard deviations (a composite score below 77.5) below the norm on either the BSID III cognitive OR BSID III motor subtests? 4. Was the participant referred for a Neurological Examination? OPT Form 97 V1 (1-1) MAR 06

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