99211 Appendices

      1. Data Submission Checklist
      2.  Eligibility Checklist/Registration Form 
      3. Performance Status Criteria
      4. Flow Sheet- TAS Sheet - Addendum
      5. Parameters Table
      6. Alcohol Use Disorders Identification Test (AUDIT)***
      7. Baseline Booklet***
      8. Twelve Week Booklet***
      9. Twenty-four Week Booklet***
      10. Usual Care Group Folder
      11. Quitline Group Folder
      12. Study Completion Form
      13. Telephone Contact Form
      14. 18 Week Encouragement Letter
      15. Early Withdrawal From Treatment Form 
      16. Declined Form
      17. Participant Contact Form


NicAlert Instructions (Please contact Sarah Hahne at shahne@wakehealth.edu to request a kit)
 Combined Appendices
Flyer (Provided as a Recruitment Tool If Needed) WFU Flyer
Fillable Medwatch

***To obtain these copyrighted forms:
 1. Please enter CCRBIS.
 2. Click on “login CCRBIS” at the top right of the CCRBIS screen.
 3. Type Username and Password.
 4. Click on “login.”
 5. Click on “Information” on the left side of the green bar at the top of the page.
 6. Use the 99211 drop-down box on the right to choose the form.
 7. Click on “99211 Forms” at left.
 8. Print.
Contact June Fletcher-Steede at jsteede@wfubmc.edu for password information.

Back to 99211 Home

Quick Reference

Research Base

Fax 336-716-6275
Phone 336-716-0891

2000 West First Street
Protocol Information Office
Suite 101
Winston-Salem, NC 27104
Find A Doctor Ways to Give
Last Updated: 06-11-2014
USNWR 2013-2014Magnet Hospital RecognitionConsumer Choice2014 Best DoctorsJoint Commission Report

Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.