REPORT DETAILS Study Name: Sponsor Number: AC Centre Name: Centre ID: Participant ID: Date of onset: __ INFORMATION SOURCE FOR FOLLOW-UP no. Name / job title of person / completing report: Email: Telephone: PI Name PI Signature: Date: ALL Reports must be signed and dated by the Principal Investigator (or suitably qualified clinician listed on the delegation log) If signatory is unavailable, the unsigned form must still be sent within 24 h reporting period __ INFORMATION SOURCE FOR FOLLOW-UP no. Name / job title of person / completing report: Telephone: PI Name PI Signature: Date: ALL Reports must be signed and dated by the Principal Investigator (or suitably qualified clinician listed on the delegation log) If signatory is unavailable, the unsigned form must be sent within 24 h reporting period __ INFORMATION SOURCE FOR FOLLOW-UP no. (if required, continue on an additional CR006-T04 form) Name / job title of person / completing report: Email: Telephone: PI Name PI Signature: Date: ALL Reports must be signed and dated by the Principal Investigator (or suitably qualified clinician listed on the delegation log) If signatory is unavailable, the unsigned form must still be sent within 24 h reporting period Original wet signature sheets must be filed in the Investigator Site File (ISF). ACCORD will retain a copy on file.
REPORT DETAILS Study Name: Sponsor Number: AC Centre Name: Centre ID: Participant ID: Date of onset: INFORMATION SOURCE FOR FOLLOW-UP no. __ Name / job title of person completing report: / Email: Telephone: PI Name PI Signature: Date: ALL Reports must be signed and dated by the Principal Investigator (or suitably qualified clinician listed on the delegation log) If signatory is unavailable, the unsigned form must still be sent within 24 h reporting period INFORMATION SOURCE FOR FOLLOW-UP no. __ Name / job title of person completing report: / Telephone: PI Name PI Signature: Date: ALL Reports must be signed and dated by the Principal Investigator (or suitably qualified clinician listed on the delegation log) If signatory is unavailable, the unsigned form must be sent within 24 h reporting period INFORMATION SOURCE FOR FOLLOW-UP no. __ (if required, continue on an additional CR006-T04 form) Name / job title of person completing report: / Email: Telephone: PI Name PI Signature: Date: ALL Reports must be signed and dated by the Principal Investigator (or suitably qualified clinician listed on the delegation log) If signatory is unavailable, the unsigned form must still be sent within 24 h reporting period Original wet signature sheets must be filed in the Investigator Site File (ISF). ACCORD will retain a copy on file.
CR006-T04%20Non-CTIMP%20SAE%20FU%20Sign-Off%20v1.0.docx