Clinical Trial Informed Consent Tracking Log Form
Record participant consent status, consent document version, and tracking details for a clinical trial informed consent process.
Participant and Study Identification
Participant Code or Study Participant ID
*
Site or Clinic Name
*
Study or Protocol Number
*
Principal Investigator or Study Coordinator Name
*
First Name
Middle Name
Last Name
Consent Document Tracking
Consent Form Version or Revision Number
*
Consent Document Title or Reference
*
Consent Status
*
Not Yet Presented
Presented for Review
Signed
Declined
Withdrawn
Consent Date and Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Confirmation and Notes
Consent Confirmation
*
Confirmed
Not Confirmed
Witness / Coordinator Name
First Name
Middle Name
Last Name
Notes / Follow-up Comments
Submit
Should be Empty: