Attachment 6a Non-physician referral instructions

Form Approved

OMB No.

Expiration Date:

Attachment 6a

Provider Referral Materials

<<Non-Physician Referral Instructions>>

Registry of Unexplained Fatiguing Illnesses and

Chronic Fatigue Syndrome (CFS)

Thank you for participating in the Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS). Please follow these instructions when considering and making a referral to the registry. If you have any questions, please refer to the Frequently Asked Questions (FAQs) for answers and telephone numbers of staff who can assist you.

1. Use the Referral Criteria Form to determine if the person is eligible.

We are looking for subjects who have had severe fatigue for a period of one month or longer and at least one other specific symptom. We do not expect you to retroactively search your files for suitable candidates. Instead, please take into consideration your patients who come to see you with a complaint of severe fatigue. If you prefer, ask your patient to help you complete the form. Afterwards, you may destroy the form or file it in your records.

2. Complete your portion of the Referral-Consent Form if your patient is eligible.

The form is perforated so that you can detach your portion (the referral) from the patient’s portion (consent to be contacted).

3. Notify Abt Associates of your referral.

You have 3 options for transferring this information to Abt Associates. Please:

1. transfer the information to our secured website:

//https:<<website address here.>>

Be sure to use the password printed on the cover letter.

2. Mail your portion in the prepaid, business return envelope; or

3. Call Abt Associates with your referral information at $$$-$$$-$$$$. Please have your password when you call.

Please remember: you must tell us of your referral. If we are contacted by a patient without receiving your referral, we will contact your office to verify that this patient was seen by you. If we cannot verify this information, the patient will not be allowed into the study.

(Instructions continue on the reserve side)

4. Give the appropriate patient recruitment packet to your patient.

Please give the manila envelope to your adult patients. If your patient is younger than 18, please give the adolescent recruitment packet (in the yellow envelope) to the adolescent’s parent or guardian.

5. Give the patient (consent to be contacted) portion of the Referral-Consent Form to your patient.

When your patient completes and signs the form, your patient is allowing Abt Associates to contact him/her about the registry.

6. Please offer to mail in the patient’s consent form to Abt Associates in the provided prepaid, business return envelope.

However, if the patient needs more time to think about consenting, please allow them to take the materials with them for consideration at a later time. If the patient takes the materials and consent form, please be sure to inform Abt Associates of the referral by submitting your portion of the referral card. Once the subject mails the consent form (or elects to provide contact information via our website or toll-free telephone number), Abt Associates will match the consent form to your referral and add your patient to our database.

7. You are done…for this patient.

The registry will be open for 12 months. We hope you will continue to keep the registry in mind as you see your patients. To help you remember our registry, we will send occasional emails to your office as a reminder.

Thank you for your participation!