12. U.S. Army Medical Research and Development Command Form 60-R
VOLUNTEER REGISTRY DATA SHEET (USAMRDC 60-R)
THIS FORM IS AFFECTED BY THE PRIVACY ACT OF 1974
AUTHORITY: 5 USC 301; 10 USC 1071-1090; 44 USC 3101; EO 9397
1.
Principal and Routine Purposes: To document participation in research conducted or sponsored by the U.S.
2.
Army Medical Research and Materiel Command. Personal information will be used for identification and
location of participants.
Mandatory or Voluntary Disclosure: The furnishing of the SSN is mandatory and necessary to provide
3.
identification and to contact you if future information indicates that your health may be adversely affected.
Failure to provide information may preclude your participation in the research study.
PART A - INVESTIGATOR INFORMATION
(To Be Completed By Investigator)
PLEASE PRINT, USING INK OR BALLPOINT PEN
1. Study Number:_____________________________
2. Protocol Title:______________________________________________________________________________
3. Contractor (Laboratory/Institute Conducting Study):________________________________________________
4. Study Period: From:_____/_____/_____
To:_____/_____/_____
DD
MM
YY
DD
MM
YY
5. Principal/Other Investigator(s) Names(s):
6. Location/Laboratory:
____________________________________
______________________/_______________________
____________________________________
______________________/_______________________
____________________________________
______________________/_______________________
PART B - VOLUNTEER INFORMATION
(To Be Completed By Volunteer)
PLEASE PRINT, USING INK OR BALLPOINT PEN
7. SSN:_______/______/______
8. Name:_________________________________________________
9. Sex: M___F___ 10. Date of Birth:____/____/____ 11. *MOS/Job Series:_____ 12: Rank/Grade:______
13. Permanent Home Address (Home of Record) or Study Location:______________________________________
(Street) or (P.O. Box/Apartment Number)
_____________________________________________________________________________________________
(City)
(Country)
(State)
(Zip Code)
Permanent Home Phone Number:_________________________________
14. *Local Address (If Different From Permanent Address):_____________________________________________
(Street) or (P.O. Box/Apartment Number)
_____________________________________________________________________________________________
(City)
(Country)
(State)
(Zip Code)
Local Phone Number:_______________________________________
15. *Military Unit: __________________________________________________ Zip Code:_________________
Organization:_____________________________ Post:_______________ Duty Phone Number:_____________