| CDE ID | CDE Description | | * 421 | EDRN Participant ID (Go To: 1066) |
| * 1066 | Date participant was determined to be ineligible (MM/DD/YYYY): (Go To: 423) |
| * 423 | EDRN Protocol ID (Go To: 422) |
| * 422 | EDRN Site ID (Go To: 929) |
| * 929 | EDRN Staff ID of the person who collected the data: (Go To: 2186) |
| * 2186 | Reason(s) for ineligibility: (Go To: 1097) |
| | | Permissible Values (value): | Participant did not meet all inclusion/exclusion criteria (2) |
|
| | | | Participant decided not to participate (10) |
|
| | | | Other, specify: (97) (Go To: 2184) |
|
| * 2184 | Reason for ineligibility (Other, specify): (Go To: 1097) |
| 1097 | Comments (do not include any participant identifiers) (Go To: End of Form) |