ࡱ>  ΀bjbjR|R| 800   xxxxx8X4.#$3333333$:683ix%%%3xxT4***%Rxx3*%3**r1T2k +%F/2o3(40X4=2z98&`929x2%%*%%%%%33*%%%X4%%%%9%%%%%%%%% >: All subjects must sign the informed consent form prior to any study-specific procedures to determine eligibility. I. Study Information Study Title: IRB Study #:Principal Investigator: II. Subject Information: Subject Name/ID:Gender:  FORMCHECKBOX  Male  FORMCHECKBOX  Female III. Inclusion/Exclusion Criteria Inclusion Criteria (From IRB approved protocol)YesNoSupporting Documentation* FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Exclusion Criteria (From IRB approved protocol) FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX !#p       + mSmm2j$h9rAhwQCJOJQJU\^JaJ,jh9rAhwQCJOJQJU\^JaJ&h9rAh9rA5CJOJQJ\^JaJh8$CJOJQJ\^JaJ h9rAh9rA#h9rAh9rACJOJQJ\^JaJh~bCJOJQJ\^JaJh8$5CJOJQJ^JaJh~b5CJOJQJ^JaJ#h9rAh9rA5CJOJQJ^JaJuvwj $Ifgd~bzkd$$IflC0 ( 0644 lalyt~b $Ifgd9rAgd9rA ~~ $Ifgd9rAxkd$$Ifl0 ( 0644 lalyt~byy $Ifgd9rAgd9rAxkd$$Ifl0 ( 0644 lalyt~b5 ~ $Ifgd9rAxkd$$Ifl0 ( 0644 lalyt*+ , - 5 6 Y l ϽydS;d/jIh9rAhwQCJOJQJU^JaJ h9rAh9rACJOJQJ^JaJ)jh9rAhwQCJOJQJU^JaJ,h9rAh9rA5B*CJOJQJ^JaJph#h9rAh9rA5CJOJQJ^JaJ&h9rAh9rA5CJOJQJ\^JaJ h9rAh9rA#h9rAh9rACJOJQJ\^JaJ,jh9rAhwQCJOJQJU\^JaJ2jh9rAhwQCJOJQJU\^JaJ5 6 7 Y l t$$$@&Ifa$gd9rA $$Ifa$gd9rA$@&gd9rAhkd$$Ifl4((0644 lalf4yt*  2 V ~ ]N@@5 x$Ifgd9rA$x$Ifa$gd9rA & Fx$Ifgd9rAkd$$Ifl4\,d(,88,0(44 lalf4yt*   , . 0 2 4 P R T V X l n p z | ~ ппппппwпpпXпп/jh9rAhwQCJOJQJU^JaJ h9rAh9rA/jh9rAhwQCJOJQJU^JaJ/j5h9rAhwQCJOJQJU^JaJ/jh9rAhwQCJOJQJU^JaJ h9rAh9rACJOJQJ^JaJ)jh9rAhwQCJOJQJU^JaJ4jh9rAh9rACJOJQJU^JaJmHnHu~  ]J<<1 x$Ifgd9rA$x$Ifa$gd9rA & FVx$If^Vgd9rAkd!$$Ifl4\,d(,88,0(44 lalf4yt*        0 2 4 > @ B D ` voWv/j5 h9rAhwQCJOJQJU^JaJ h9rAh9rA4jh9rAh9rACJOJQJU^JaJmHnHu/j(h9rAhwQCJOJQJU^JaJ/jh9rAhwQCJOJQJU^JaJ h9rAh9rACJOJQJ^JaJ)jh9rAhwQCJOJQJU^JaJ/j<h9rAhwQCJOJQJU^JaJ  B f ]J<<1 x$Ifgd9rA$x$Ifa$gd9rA & FVx$If^Vgd9rAkd$$Ifl4\,d(,88,0(44 lalf4yt*` b d f h voWv/j h9rAhwQCJOJQJU^JaJ h9rAh9rA4jh9rAh9rACJOJQJU^JaJmHnHu/j h9rAhwQCJOJQJU^JaJ/j! 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The method of confirmation can include, but is not limited to, laboratory test results, radiology test results, subject self-report, and medical record review. IV. Statement of Eligibility This subject is  FORMCHECKBOX  eligible /  FORMCHECKBOX  ineligible for participation in the study based on the inclusion/exclusion criteria described in the IRB submission, as approved by the IRB. PI/designee signature*:Date**:Printed name of person assessing eligibility :Printed name of person completing this form: * This form should be signed by the PI or designee, as described on the delegation of authority log. ** Documentation of eligibility determination should be completed prior to study start. NOTE: Enrollment exceptions are protocol deviations. They can be submitted on a Report Form prior to enrolling the subject. The protocol and consent do not need to change for one exception. If there is no time for an actual submission, contact the IRB at  HYPERLINK "mailto:irb@slu.edu" irb@slu.edu for approval and submit the Report Form in eIRB as soon as possible.     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