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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
• Instructions
• Study Visits and Procedures
• Week 6 Booklet***
• Clearing the Air Booklet
• Letter to Participants from Doctor
• Tobacco Cessation Guide for Doctor
11. Quitline Group Folder
• Instructions
• Study Visits and Procedures
• Week 6 Booklet***
• Quitline Enrollment Form
• Benefits of Quitting Smoking Handout
• What Happens Next Handout
• Nicotine Replacement Diary
• Letter to Participants from Doctor
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.

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