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Center for Health Sciences
Family Medicine
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Division of Research

Cranial OMT/Otitis Media Study

Instructional & Informational Forms
Informed Consent: Information participants should be aware of, covers criteria for becoming involved in the study, what is expected of participants, and what is involved in treatments. Word | PDF

Filling out Form1A: Instructions for filling out Form 1A-Chart Review. Word | PDF

Cranial SOAP Note Form Usage: Instructions for filling out the Cranial SOAP Note form. Word | PDF

How the Money Works: Explains how funds are calculated and distributed. Word | PDF

Data Collection Forms
Informed Consent:  Must be completed for the patient to participate in the study. Word | PDF

Form 1A-Chart Review: Help determine eligibility for participation in the study. Begun prior to the patient's first visit, form should be completed when patient finishes the study protocol. Word | PDF

Form 1B-Eligibility Criteria, ID and Randomization: Completed when enrolling a patient in the study. Word | PDF

Form 1C-Demographics: Completed at patient's first visit, collects background information about patient. Word | PDF

Form 1D-Audiology: Completed by examining audiologist at both the beginning and end of patient's participation in the study. Word | PDF

Form 2A-Hearing Behavior Rating: Tracks behaviors related to otitis media, to be completed at each of patient's visits (and telephone contacts if patient is in the control group). Word | PDF

Form 2B-Clinical Update: Completed with Form 2A at every patient contact, tracks any prescription and over-the-counter medications taken by patient. Word | PDF

Form 2C-Tympanogram: Completed at specified intervals throughout the study; patient's tympanogram strips are attached. Word | PDF

Form 3-Cranial SOAP Note: Osteopathic Manipulation Exam and Treatment Form (with Cranial Emphasis).  Word | PDF

Data Management Forms
Appointment Schedule-Control Group: Tracks a single patient in the control group for dates of all encounters and visits, forms completed and submitted, and payments received. Word | PDF

Appointment Schedule-Treatment Group: Tracks a single patient throughout the study. Word | PDF

OMT Study Participation Summary: Summary of a single patient's participation in the study including the patient chart. Word | PDF

Patient Roster/Status: Tracks multiple patients (treatment and control) throughout study. Word | PDF

Site Coordinator Task Flowchart:  Overview of site coordinator's responsibilities. Word | PDF