Coordinator Event Summary

Please complete this form and submit.

Event Date*
MM slash DD slash YYYY
Event Number (ex: 12345)*
Client*
Event Location*
Primary Contractor's Name*
Who was your TotalWellness Account Manager?*
Event Type*
Type of Screenings*
Number of screening participants*
Were blood samples collected on every participant?*
- Yes
- No
How many participants were you unable to collect blood samples on?*
Number of flu shots administered*
Number and type of additional procedures provided (ex: 5 PSA, 3 Step Test)
Did you utilize iPads to collect data electronically on-site?*
- Yes, all participants were entered into the iPad
- Yes, but paper consent forms were used for some participants
- No, I switched to paper consent forms for all participants
- No, the event was setup to use paper consent forms only
How many paper consent forms were not entered into the iPad?*
Did the event start on time?*
Please provide start time and explanation:*
Did the event end on time?*
Please provide end time and explanation:*
Did you complete a time extension form?*
Which statement best describes your overall event success?*
Please provide feedback regarding the overall event success (i.e. participant feedback, site contact feedback, etc.)*
Please list any issues that affected the outcome of the event (IE. missing supplies, staff issues, large number of re-sticks, etc.)
Please upload the following documents.
Time Log - Page 1*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Time Log - Page 2
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Time Extension Form*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Incident Report (if applicable)
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
CRL Participant Sign-In Sheet(s) with Barcodes*
Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, Max. file size: 50 MB.
CRL Wellness Sample Tracking Form*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Original fingerstick paper consent forms should be returned to TotalWellness using FedEx Overnight - Account Number: 227999381.
Original paper consent forms for venipuncture services should be sent to CRL with the blood samples. All other paperwork can be returned to TotalWellness with your supplies.
Original paper consent forms for flu shot services should be returned to TotalWellness with your return vaccine or return supply shipment.

9320 H Court, Omaha, NE 68127 | 402.964.0542