GOBO PI Screening checklist

GOBO Screening Sign Off

"*" indicates required fields

Trial Coordinator name*

Participant ID*

Screening Number*

Product Number

Informed consent

Provided

Not provided

Screening sign off

	Passed	Failed	Not completed
Phone Screen Inclusion
Phone Screen Exclusion
DHA/EPA Food Frequency
Screen #1 Weight and BMI
Screen #2 Vitals
Screen #3 Medical Assessment
Screen #4 Urine Drug Screen
Screen #4 Urine Pregnancy Screen
Screen #4 Cholesterol/Triglycerides
Omega-3 Index
Pathology Safety Screen

Does the subject have any condition which, in the opinion of the investigator makes the subject unsuitable for inclusion?

Yes

Has the subject passed all the inclusion criteria and none of the exclusion criteria and been deemed healthy?

Yes, passed screening

No, inelligible

PI Name/Wet ink Signature

Date