INVESTIGATIONAL PRODUCT (IP) Not Applicable (please continue to #7) DRUG, BIOLOGIC, OR NATURAL HEALTH PRODUCT (if more than 1, list separately) Type DIN or Manufacturer How will IP be Supply Source Use in the study # obtained? 1 Drug #: Name: Purchased Manufacturer Dose: Biologic Country: Donated Wholesaler Schedule: Natural Health Importation? No Yes Commercial supply Route: Product Other: Study indication: 2 Drug #: Name: Purchased Manufacturer Dose: Biologic Country: Donated Wholesaler Schedule: Natural Health Importation? No Yes Commercial supply Route: Product Other: Study indication: 3 Drug #: Name: Purchased Manufacturer Dose: Biologic Country: Donated Wholesaler Schedule: Natural Health Importation? No Yes Commercial supply Route: Product Other: Study indication: 4 Drug #: Name: Purchased Manufacturer Dose: Biologic Country: Donated Wholesaler Schedule: Natural Health Importation? No Yes Commercial supply Route: Product Other: Study indication: PLACEBO Supply source:
INVESTIGATIONAL PRODUCT (IP) Not Applicable (please continue to #7) DRUG, BIOLOGIC, OR NATURAL HEALTH PRODUCT (if more than 1, list separately) Type DIN or # Manufacturer How will IP be obtained? Supply Source Use in the study 1 Drug Biologic Natural Health Product #: Name: Country: Importation? No Yes Purchased Donated Manufacturer Wholesaler Commercial supply Other: Dose: Schedule: Route: Study indication: 2 Drug Biologic Natural Health Product #: Name: Country: Importation? No Yes Purchased Donated Manufacturer Wholesaler Commercial supply Other: Dose: Schedule: Route: Study indication: 3 Drug Biologic Natural Health Product #: Name: Country: Importation? No Yes Purchased Donated Manufacturer Wholesaler Commercial supply Other: Dose: Schedule: Route: Study indication: 4 Drug Biologic Natural Health Product #: Name: Country: Importation? No Yes Purchased Donated Manufacturer Wholesaler Commercial supply Other: Dose: Schedule: Route: Study indication: PLACEBO Supply source:
cts-intake-form-and-services-list-20160517.docx