Form 194 - Qlft Withdrawal Form

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Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail . Include the Web site and filename in your message.
Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail . Include the Web site and filename in your message.
HALT-C Trial
QLFT Withdrawal Form
Form # 194
Version A: 06/15/2000
SECTION A: GENERAL INFORMATION
A1. Affix ID Label Here 
___ ___ - ___ ___ ___ - ___
A2. Patient initials: __ __ __
A3. Form completion date: MM/DD/YYYY
__ __ / __ __ / __ __ __ __
A4. Initials of person completing form: __ __ __
SECTION B: WITHDRAWAL INFORMATION
B1. Date of withdrawal:
__ __ / __ __ / __ __ __ __
(MM/DD/YYYY)
B2. Primary reason for withdrawing from the QLFT study:
(CIRCLE ONE REASON.)
Insufficient sampl e c o l l e c t i o n …………………………1
P a t i e n t w i t h d r e w c o n s e n t . ……………………………. 2
O t h e r …………………………………………………. . . 9 9
If other, then specify: _____________________________
B3. Additional Comments:
_______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
HALT-C Trial
Form # 194
Version A: 06/15/2000
Page 1 of 1

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