Authorization Cover Letter Template Page 7

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A
VI
PPENDIX
P
N
-R
L
: R
F
S
(
)
ATHOLOGY LABORATORY
ON
ESPONSE
OG
EQUEST
OR
PECIMEN
S
Instructions:
The Non-response Log should be used to document effort to obtain remnant tissue from a pathology lab. Guidelines for follow-up effort are
included in the Remnant Tissue MOP section 3.2.
Section I: Participant Data
Section II
ACRIN NLST Inst #
Pathology Lab Name
ACRIN NLST Case #
Pathology Lab Address
Participant Initials:
Pathology Lab Address
Pathology Lab Address
Contact Person at Lab
Phone
Fax
Section III: Call Record
Date of first mailing: ______________________
Date of last contact: ______________________
Outcome of Call
Reason for Refusal
Level of Refusal
Comments:
Day: _____________
No Answer
Too Busy
Mild
Date:
/
/2009
Busy
Not Interested
Firm
:
AM
Time of call:
Call Back
Call Back
Hostile
Left Message
Other, specify:
:
PM
Already Sent
Initials:
Refusal
Outcome of Call
Reason for Refusal
Level of Refusal
Comments:
Day: _____________
No Answer
Too Busy
Mild
Date:
/
/2009
Busy
Not Interested
Firm
:
AM
Time of call:
Call Back
Call Back
Hostile
Left Message
Other, specify:
:
PM
Already Sent
Initials:
Refusal
Outcome of Call
Reason for Refusal
Level of Refusal
Comments:
Day: _____________
No Answer
Too Busy
Mild
Date:
/
/2009
Busy
Not Interested
Firm
:
AM
Time of call:
Call Back
Call Back
Hostile
Left Message
Other, specify:
:
PM
Already Sent
Initials:
Refusal
Outcome of Call
Reason for Refusal
Level of Refusal
Comments:
Day: _____________
No Answer
Too Busy
Mild
Date:
/
/2009
Busy
Not Interested
Firm
:
AM
Time of call:
Call Back
Call Back
Hostile
Left Message
Other, specify:
:
PM
Already Sent
Initials:
Refusal
Page 17 of 17

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