Research Participant Intake Record Checklist Form
Complete this form to record and verify essential details for each research participant intake. Ensure all checklist items are addressed for a smooth intake process.
Participant Full Name
*
First Name
Last Name
Preferred Contact Email
*
example@example.com
Preferred Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Study or Project Name
*
Participant ID or Intake Reference (internal use only)
*
Intake Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Research Area or Study Type
Please Select
Behavioral Science
Clinical Research
Social Science
Public Health
Education
Other
Recruitment Source
Please Select
Online Advertisement
Referral
Event/Outreach
Database/Registry
Social Media
Other
Intake Checklist (select all completed)
Eligibility confirmed
Consent form reviewed with participant
Consent form signed
Participant information sheet provided
Study materials provided
Contact preferences confirmed
Compensation details discussed
Questions answered
Other (please specify)
Staff Notes or Follow-Up Comments
Submit Intake Record
Should be Empty: