OPT Form 97 V1 (1-1) MAR 06

1
CONFIRMATION OF STUDY VISIT / REPORT OF MISSED
VISIT
1. Did the subject attend the visit?
2. List assessment tools completed at this visit
3. Did the child score more than 1.5 standard
deviations (a composite score below 77.5)
below the norm on either the BSID III cognitive
OR BSID III motor subtests?
4. Was the participant referred for a
Neurological Examination?
OPT Form 97 V1 (1-1) MAR 06