ࡱ > Y [ X w bjbj 5( X 1 1 1 1 1 E E E 8 } T E ) 0 Y 1 1 1 ` ` ` R 1 1 ` ` ` ` p+ E F ` 0 ) ` d ` 1 ` X ` ` ) : Study Drug Accountability Log
Protocol Name/Number: _____________________________
Subject Initials/ID #: _________________/______________________ Site #: ________
Item Description: (i.e. A Kit will contain 5 blister cards, each with 7 rows of tablets in 4 columns; full blister card contains 28 tablets total.
A full kit contains 140 tablets total.)
DISPENSING INFORMATION
RETURN INFORMATION
SPONSOR or Pharmacist
COMMENTS
Date
Kit Number
Lot Number
Expiration Date
# of tabs
Staff Initials
Date
# of tabs
returned
Staff Initials
Date/
InitialsDay 1
140Week 4
140Week 8
140Week 12
140
Sponsor VerificationInitialsDateInitialsDateInitialsDateInvestigator SignatureDateWhen the log has been completed, the investigator (or documented designee) signs and dates this log to verify that all records are accurate, current and will be made available upon request.
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Page ______ of _______ 15-Apr-13
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