Header
PI Name
text
Protocol or IRB Number
integer
Protocol Short Title
Subject Initials
Subject ID
Date
date
Demographics
Subject UWHC Medical Record Number
First Name
Middle Name (or initial)
Last Name
Birthdate
Gender
Ethnicity
Race
boolean
Other Medical Record Number(s)
Medical Record Number
Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
Contact Information
Address
Unit number
City
State
Zip
Phone number
Alternate Phone Number
Email address
Preferred method of contact
Emergency contact
Name
Phone Number
Form completed By