Encounter Form Diabetes Prevention Trial - Type 1
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Form EI
Diabetes Prevention Trial - Type 1
Page 1 of 2
ENCOUNTER FORM
Complete this form each time an encounter (either phone contact or a clinic visit)
occurs with the subject for any of the ‘Reasons for encounter’ listed below.
/
/
Subject ID #:
Subject Initials:
Date:
F M
L
M M
D D
Y Y
/
/
Date of Visit:
M M
D D
Y Y
Name of person completing form (please print): ___________________________________________
All Subjects:
1.
Reasons for encounter (check all that apply):
Baseline Visit (Testing Location Code (TLC) for reimbursement:
)
Routine follow-up visit per protocol* (every 6 months) (TLC for reimbursement:
)
Treatment adjustment (for Parenteral Antigen/Experimental Treatment subjects only)
Suspected adverse event (*submit adverse event form)
Follow-up call to ‘800’ complications line (*submit adverse event form)
Counseling/education
Pregnancy (*submit pregnancy form)
Symptoms of diabetes
Study end visit (TLC for reimbursement:
)
Other (specify, ___________________________________________________)
* Please note that only one Routine follow-up Visit will be reimbursed each 6-month period. If multiple
EI forms indicating a follow-up visit was completed are received in DMU within the projected time
window around the scheduled 6-month visit, the form with the earliest date will be used to determine
reimbursement.
2.
Do you suspect that the subject is taking any of the following?
1=No 2=Yes 3=Don’t Know
Insulin not called for by DPT-1 protocol
Nicotinamide
Steroids
Immunosuppressive medication
If yes to any, explain: _________________________________________________________
DMU Use Only
EI01 - REV 09/26/97
Date rcvd:
E
I
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