• Research ›

99311 Appendices

1. Data Submission Checklist  

2. Eligibility Checklist/Registration Form

3.  Performance Status Criteria

4.  Patient Medication Diary

5.  MedWatch

6. Flow Sheet- TAS Sheet - Addendum

7.  Parameters Table

8.  Behavioral Risk Factor Surveillance Survey (BRFSS)

9.  Self-Reporting Tobacco Abstinence in Past Week Form  

10.  Fagerstom Nicotine Tolerance Scale

11.  Wisconsin Inventory of Smoking Dependent Motive

12. Wisconsin Smoking Withdrawal Scale

13.  SF12 Questionnaire    

15.  Decline Form

16.  Early Withdraw Form

 Combined Appendices

Helpful Tools:
Sample Recruitment Letter 
Flyer 
 NicAlert Instructions

99311 Home