Baseline Laboratory Evaluation

Is this an original or revised submission?

Original

Revised

Name of the Person Entering Data into this CRF

First Name

Last Name

Date of Blood Urea Nitrogen (BUN)

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DD

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Date of Creatinine (CR)

MM

DD

YYYY

Date of White Blood Cells (WBC)

MM

DD

YYYY

Date of Hemoglobin (HGB)

MM

DD

YYYY

Date of Hematocrit (HCT)

MM

DD

YYYY

Date of Platelets (PLT)

MM

DD

YYYY

Date of Prothrombin Time (PT)

MM

DD

YYYY

Date of Partial Thromboplastin Time (PTT)

MM

DD

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Date of International Normalized Ratio (INR)

MM

DD

YYYY

Attestation *

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

Date of Completion

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DD

YYYY