Protocol Entry form

  

Protocol Info: PI Information: Contact Information:
Date: *PI: Contact:
  *Phone: (Format: 123-456-7890) Phone:
*IRB Number: (Format: #i/C#) Email: Email:
Protocol Type:
Protocol Title:
Notes:
Study Information:
Number of Participants Needed: Outpatients
Controls
Approx. duration of 1st Visit (specify hrs or min)
Duration of subsequent visits (specify hrs or min)
Number of Study Visits:
Payment $
Payment Details
(i.e., payment by hr., visit, group of visits)
 Description:
Demographic Inclusion Criteria: Volunteers with any of the characteristics you select will be INCLUDED in the protocol.
Gender: Male
Female
AGE: Min:

Max:
Ethnicity: Spanish origin, Hispanic or Latino
Not Hispanic or Latino
Race: American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
     Other Pacific Islander
White
Handedness: Left Hand Favored
Right Hand Favored
ambidextrous
Education Code:

 Graduate/professional training
      (graduate degree)
Standard college or university graduation
Partial college (at least one year or
      specialized training)
High School Graduate
Partial high school (10th or 11th grade)
Junior high school (including 9th grade)
Less than seventh grade
Native Language: English
Spanish
Asian Dialect
African Dialect
Indian Dialect
Other
Diagnosis Inclusion Criteria:
   Outpatients only
   Please enter DSM-IV criteria for Outpatients. Only patients matching AT LEAST ONE of the these diagnoses will be eligible.
   To include sub-codes for a category use "%" as a wild card symbol. (e.g., 296% will match to 296.1, 296.89, etc.)
For a list of DSM codes.
Current Brief desc. of code
Lifetime Brief desc. of code
Medical Information Exclusion Criteria: Select all conditions you want EXCLUDED from your protocol.
Exclude
Subject has contraindications to MRI, such as claustrophobia, permanent metal in or on body, pacemaker, migraines,
bone or joint pins, metal plates, IUD, etc. (or if body shape not compatible with magnet, etc)? (Is not MRI compatible.)
Subject is currently pregnant
Subject is hearing impaired
Subject is vision impaired (and not corrected to normal with glasses or contacts)
Subject has history of stroke
Subject has history of seizure or epilepsy
Subject has history of significant head injury (i.e., with loss of consciousness greater than 30 minutes?)
Subject is known HIV positive
Family Information
Subject is NOT in contact with biological family
   DIAGNOSIS EXCLUSION CRITERIA (CONTROLS AND OUTPATIENTS)
   Check the diagnoses that will EXCLUDE controls and patients from the protocol.
DIAGNOSIS Control
CURRENT 		Control
LIFETIME 		OutPatient
CURRENT 		OutPatient
LIFETIME
Bipolar I
Bipolar II
Major Depression
Dysthymic
Schizophrenia
Schizoaffective
Alcohol (Abuse)
Alcohol (Dependence)
Sedative-Hypno (Abuse)
Sedative-Hypno (Dependence)
Cannabis (Abuse)
Cannabis (Dependance)
Opioid (Abuse)
Opioid (Dependence)
Cocaine (Abuse)
Cocaine (Dependence)
Hallucinogen (Abuse)
Hallucinogen (Dependence)
Poly Drug (Dependence)
Other (incl. Stim.) (Abuse)
Other (incl. Stim.) (Dependence)
Anxiety Disorders
Panic Disorder
Specific Phobia
OCD
PTSD
Generalized Anxiety
Somatoform (NOS)
Eating Disorders
Adjustment Disorder