Administrative data
Subject Identifier
integer
Urine Drug, Alcohol and Cotinine Screen
Date of sample taken
date
Time of sample taken
time
Mark appropriate box(es)
Cocaine
text
Amphetamines
Benzodiazepines
Cannabinoids
Opiates
Barbiturates
Alcohol
Cotinine
If any of the above are positive, exclude subject from the study.
Serology - HIV, Hepatitis B & C Screen
Date sample taken
HIV antibody
Hepatitis B surface antigen
Hepatitis C antibody