91105 Appendices

91105 Appendices

Phase III Double Blind, Placebo Controlled Study of
Donepezil in Irradiated Brain Tumor Patients

Appendices:

1.    Data Submission Checklist
2.    Eligibility Checklist/Registration Form
3.    Performance Status Criteria
4.    Patient Medication Diary
5.    MedWatch
6.    Flow Sheet
7.    TAS (Toxicity Assessment Sheet)
8.    Patient Survey Form
9.    Telephone Contact Form
10. Current Medication Form
11. Certification Procedures
12. Baseline Booklet*
13. 12 Week Booklet*
14. 24 Week Booklet*
15. MRI CD Submission Form

Help Tool: Medication Lists

*1.To obtain these copyrighted forms, please enter CCRBIS.
2. Click on “login CCRBIS” at the top right of the CCRBIS screen.
3. Type Username and Password.
4. Click on “login.”
5. Click on “Information” in upper left hand corner.
6. Use the second drop-down box on the right to choose booklet. (Baseline,12 wk, or 24 wk)
7. Click on “Forms” at left.

Contact June Fletcher-Steede at jsteede@wfubmc.edu for password information.

WFU Use Only

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The information on this Website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified healthcare provider. If you have a medical problem or a health-related question, consult your physician or call Health On-Call at 336-716-2255 or 1-800-446-2255.

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Last Modified: 11/6/2008

[Website Access Agreement] [Privacy Notices] [Copyright Information] [Campus Security Act]

Copyright: Wake Forest University School of Medicine and North Carolina Baptist Hospitals. All rights reserved.
Medical Center Boulevard
Winston-Salem, NC 27157

The information on this Website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified healthcare provider. If you have a medical problem or a health-related question, consult your physician or call Health On-Call at 336-716-2255 or 1-800-446-2255.

Send Feedback	Home	Site Index
	Last Modified: 11/6/2008