study exit — 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

Date of Study Exit

YYYY

Reason for Study Exit

Patient voluntarily exited the study and did not complete the study treatment and/or follow-up as planned (see below).

Patient's participation the study was terminated by the investigator (see below).

Patient completed the study course of treatment and follow-up as planned.

Please provide an explanation if the patient did not successfully complete the study procedure and all follow-up.

Attestation

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

Date of Completion

YYYY