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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 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 for password information.

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Research Base

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


Medical Center Boulevard, 525@Vine 4th floor
Box 573152
Winston-Salem, NC 27157
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Last Updated: 03-16-2015
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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.

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