Authorization Cover Letter Template Page 3

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A
III
PPENDIX
P
N
-R
L
: R
A
ARTICIPANT
ON
ESPONSE
OG
EQUEST FOR
UTHORIZATION
S
1: P
D
ECTION
ARTICIPANT
ATA
NLST ACRIN Case #:
Participant initials:
Date of First Mailing:
S
II: C
R
ECTION
ALL
ECORD
Date of first mailing:
Date of last contact:
Outcome of Call
Reason for Refusal
Comments:
Day: _____________
Level of Refusal
No Answer
Too Busy
Date:
/
/2009
Mild
Busy
Not Interested
:
AM
Time of call:
Firm
Call Back
Call Back
Hostile
:
Left Message
PM
Other, specify:
Already Sent
Initials:
Refusal
Outcome of Call
Reason for Refusal
Comments:
Day: _____________
Level of Refusal
No Answer
Too Busy
Date:
/
/2009
Mild
Busy
Not Interested
:
AM
Time of call:
Firm
Call Back
Call Back
Hostile
:
Left Message
PM
Other, specify:
Already Sent
Initials:
Refusal
Outcome of Call
Reason for Refusal
Comments:
Day: _____________
Level of Refusal
No Answer
Too Busy
Date:
/
/2009
Mild
Busy
Not Interested
:
AM
Time of call:
Firm
Call Back
Call Back
Hostile
:
Left Message
PM
Other, specify:
Already Sent
Initials:
Refusal
Outcome of Call
Reason for Refusal
Comments:
Day: _____________
Level of Refusal
No Answer
Too Busy
Date:
/
/2009
Mild
Busy
Not Interested
:
AM
Time of call:
Firm
Call Back
Call Back
Hostile
:
Left Message
PM
Other, specify:
Already Sent
Initials:
Refusal
Outcome of Call
Reason for Refusal
Comments:
Day: _____________
Level of Refusal
No Answer
Too Busy
Date:
/
/2009
Mild
Busy
Not Interested
:
AM
Time of call:
Firm
Call Back
Call Back
Hostile
:
Left Message
PM
Other, specify:
Already Sent
Initials:
Refusal
Page 13 of 17

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