Tip for Study-specific

Be completely honest about your medical history and medications — undisclosed information can put you at risk

Tip for Study-specific

Screening procedures are typically free to you

Tip for Study-specific

If you do not meet eligibility criteria for one study, the team may know of other studies you could qualify for

Clinical TrialsmoderateDoctor signature required

Eligibility Screening / Inclusion-Exclusion Checklist

Study-specific · Study sponsor

Checklist confirming the participant meets all inclusion criteria and no exclusion criteria for the clinical trial.

Form Details

Total fields: 40
Auto-fillable: 25 (63%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: doctor
Frequency: one time

Fill this form with BeneFill

Auto-fill 63% of fields from your profile. Save 22 minutes. Download a real PDF.

25 of 40 fields63% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

🏢

Completed at the clinical trial site during the screening visit

The research coordinator or investigator will review eligibility criteria with you.

🌐

Some studies offer pre-screening questionnaires online

Check ClinicalTrials.gov or the study website for online pre-screening options.

🌐

Pre-screening by phone with the research coordinator

Call the study contact listed on ClinicalTrials.gov to discuss initial eligibility.

Required Attachments

📎 Signed informed consent form (required before any screening procedures)
📎 Complete medical history and current medications
📎 Relevant medical records, lab results, and imaging
📎 Screening lab work and assessments (ordered by the study team)

Processing Time

Screening periods vary by study — typically 1-4 weeks. Complex studies may have longer screening windows.

What Happens Next

The research team will review all screening data against the study's inclusion/exclusion criteria. You will be notified whether you are eligible to participate. If eligible, you will be enrolled and scheduled for the first study visit.

Tips for This Form

✓ Be completely honest about your medical history and medications — undisclosed information can put you at risk
✓ Screening procedures are typically free to you
✓ If you do not meet eligibility criteria for one study, the team may know of other studies you could qualify for
✓ Find clinical trials at https://clinicaltrials.gov or ask your doctor about relevant studies

More Clinical Trials Forms

Informed Consent Document (ICF)

Study-specific · Study sponsor / institution

Comprehensive document explaining the clinical trial: purpose, procedures, risks, benefits, alternatives, voluntariness, and right to withdraw. Must be approved by IRB.

HIPAA Authorization for Research

Institution-specific · Research institution

Separate authorization for use and disclosure of PHI for research purposes. May be broader than clinical HIPAA authorization.

Individual Patient Expanded Access IND Application

FDA Form 3926 · U.S. Food and Drug Administration

Simplified form for requesting compassionate use of investigational drugs for patients with serious or life-threatening conditions and no alternatives. FDA approves over 99% of requests. Requires manufacturer agreement to provide the drug.

Investigational New Drug Application (IND)

FDA Form 1571 · U.S. FDA

Traditional IND application form for expanded access submissions. Form 3926 is the simplified alternative for individual patients.

Statement of Investigator

FDA Form 1572 · U.S. FDA

Statement of investigator qualifications and commitment to conduct the study per FDA regulations. Accompanies IND submissions.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Study sponsor or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.