randomization — Albany IR

Site

Patient Number

Please enter in three digit format (e.g., 001, 002, ..., 025)

Is this an original or revised submission?

Original

Revised

Name of the Person Entering Data into this CRF

First Name

Last Name

RANDOMIZATION

Date of Randomization

YYYY

Envelope Number

Randomization Assignment

Embozene Microspheres

Embosphere Microspheres

Attestation

I approve the data entered into this CRF and attest to its accuracy.

Date of Completion

YYYY

Text

Please specify if "other" is selected above.