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03 section 1.3b. screening log v1.0

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					                                                                               Screening Log
                                                                  EudraCT number: 2007-006185-15
                   SPIRIT   2 CML TRIAL
SITE NUMBER:                                        SITE:
PRINCIPAL INVESTIGATOR:                             PRINCIPAL INVESTIGATOR SIGNATURE:


        Patient Name          Hospital Number   Screening Date        Eligible for study?   Agreeable to study?


1


2


3


4


5




Sheet number:1                                                                Version 1 – 27 November 2008
                                                                              Screening Log

                                                                 EudraCT number: 2007-006185-15
                   SPIRIT   2 CML TRIAL
SITE NUMBER:                                       SITE:
PRINCIPAL INVESTIGATOR:                            PRINCIPAL INVESTIGATOR SIGNATURE:


        Patient Name         Hospital Number   Screening Date        Eligible for study?   Agreeable to study?


 6


 7


 8


 9


10




Sheet number:2                                                               Version 1 – 27 November 2008
                                                                               Screening Log


                                                                  EudraCT number: 2007-006185-15
                   SPIRIT   2 CML TRIAL
SITE NUMBER:                                        SITE:
PRINCIPAL INVESTIGATOR:                             PRINCIPAL INVESTIGATOR SIGNATURE:


        Patient Name          Hospital Number   Screening Date        Eligible for study?   Agreeable to study?


11


12


13


14


15




Sheet number:3                                                                Version 1 – 27 November 2008
                                                                              Screening Log



                                                                 EudraCT number: 2007-006185-15
                   SPIRIT   2 CML TRIAL
SITE NUMBER:                                       SITE:
PRINCIPAL INVESTIGATOR:                            PRINCIPAL INVESTIGATOR SIGNATURE:


        Patient Name         Hospital Number   Screening Date        Eligible for study?   Agreeable to study?


16


17


18


19


20




Sheet number:4                                                               Version 1 – 27 November 2008

				
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