Screening Questions Containing Identifiable Information Page 2

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_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________
4. Will names or other identifying information be associated with the screening failure data that will be provided to
individuals not listed on this application?
Yes  Explain why names or other identifying information will be associated with the data: ________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
No
NOTE: If identifiable information will be provided to persons not listed on this application, permission to
release this data must be obtained from the individual participant.
NOTE: Attach, as appropriate, a procedure and script for the screening questions.
Also,
attach
a copy of the screening question data collection sheet.

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