| When (Pacific) | Who | Participant | Form | Action | Changes (old → new) |
|---|---|---|---|---|---|
| 11/12/2026 17:17 | Local (login disabled) local | TLIC-004 | Source Data Worksheet | Reviewed | Marked reviewed (✓) while the section was still incomplete |
| 11/12/2026 17:11 | Local (login disabled) local | TLIC-004 | Source Data Worksheet | Reviewed | Marked reviewed (✓) while the section was still incomplete |
| 11/12/2026 17:11 | Local (login disabled) local | TLIC-004 | Source Data Worksheet | Saved | Consent process 1: Each section of the study consent form was reviewed with the subject.: — → Yes Consent process 2: The subject was given an opportunity to ask questions.: — → Yes Consent process 3: The subject understands the risks and benefits of the study.: — → Yes Consent process 4: The California Bill of Rights was provided to the subject.: — → Yes Consent process 5: HIPAA Consent was signed and dated.: — → Yes Consent process 6: A copy of the signed Consent Form was provided to the subject.: — → Yes |
| 11/12/2026 17:10 | Local (login disabled) local | TLIC-004 | Patient Consent | Signed | Signature of Subject (18 years and older) — Authorization: — → Amit Johanis · 11/12/2026 |
| 11/12/2026 17:10 | Local (login disabled) local | TLIC-004 | Patient Consent | Signed | Signature of Person Conducting Informed Consent Discussion: — → Local (login disabled) · 11/12/2026 |
| 11/12/2026 17:09 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: No → Yes |
| 11/12/2026 17:09 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: Yes → No |
| 11/12/2026 17:09 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: No → Yes |
| 11/12/2026 17:09 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: Yes → No |
| 11/12/2026 17:08 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: No → Yes |
| 11/12/2026 17:08 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: Yes → No |
| 11/12/2026 17:08 | Local (login disabled) local | TLIC-004 | Patient Consent | Signed | Signature of Subject (18 years and older) — Consent: — → Amit Johanis · 11/12/2026 |
| 11/12/2026 17:08 | Local (login disabled) local | TLIC-004 | Patient Consent | Signed | |
| 11/12/2026 17:08 | Local (login disabled) local | TLIC-004 | Patient Consent | Signed | Signature of Participant — Yes, I agree to be contacted for future research studies: — → Amit Johanis · 11/12/2026 Signature of Participant — No, I do not want to be contacted for future research studies: Amit Johanis · 11/12/2026 → — |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Signed | Signature of Participant — No, I do not want to be contacted for future research studies: — → Amit Johanis · 11/12/2026 Signature of Participant — Yes, I agree to be contacted for future research studies: Amit Johanis · 11/12/2026 → — |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Signed | Signature of Participant — Yes, I agree to be contacted for future research studies: — → Amit Johanis · 11/12/2026 |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: No → Yes |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: Yes → No |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: No → Yes |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: Yes → No |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: No → Yes |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: Yes → No |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: No → Yes |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Saved | Impartial witness used: Yes → No |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Patient Consent | Created | Impartial witness used: — → Yes |
| 11/12/2026 17:07 | Local (login disabled) local | TLIC-004 | Source Data Worksheet | Created | Visit Date: — → 11/12/2026 Consent Signed: — → No Staff Initials: — → cd Consent Date: — → 11/12/2026 First Name: — → Amit Last Name: — → Johanis |