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MTN-013 Combined SE Log

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MTN-013 Combined SE Log Powered By Docstoc
					                        Phase 1 Safety and Pharmacokinetics of Dapivirine/Maraviroc Intravaginal Ring (Version 1.0 dated April 1, 2011)
                                                                 [Site Name and Location]

                                            MTN-013/IPM 026 Screening and Enrollment Log
                                                                                          Screening Failure/
                                                                      Enrollment date      Discontinuation              Reason for Screening
      Screening   Screening      Participant ID     Date Screening      (or NA if not       Date (or NA if             Failure/Discontinuation   Staff Initials
No.    Attempt     Date(s)           (PTID)         Window Closes         enrolled)           enrolled)                   (or NA if enrolled)     and Date
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                        Phase 1 Safety and Pharmacokinetics of Dapivirine/Maraviroc Intravaginal Ring (Version 1.0 dated April 1, 2011)
                                                                 [Site Name and Location]

                                            MTN-013/IPM 026 Screening and Enrollment Log
                                                                                          Screening Failure/
                                                                      Enrollment date      Discontinuation              Reason for Screening
      Screening   Screening      Participant ID     Date Screening      (or NA if not       Date (or NA if             Failure/Discontinuation   Staff Initials
No.    Attempt     Date(s)           (PTID)         Window Closes         enrolled)           enrolled)                   (or NA if enrolled)     and Date
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                        Phase 1 Safety and Pharmacokinetics of Dapivirine/Maraviroc Intravaginal Ring (Version 1.0 dated April 1, 2011)
                                                                 [Site Name and Location]

                                            MTN-013/IPM 026 Screening and Enrollment Log
                                                                                          Screening Failure/
                                                                      Enrollment date      Discontinuation              Reason for Screening
      Screening   Screening      Participant ID     Date Screening      (or NA if not       Date (or NA if             Failure/Discontinuation   Staff Initials
No.    Attempt     Date(s)           (PTID)         Window Closes         enrolled)           enrolled)                   (or NA if enrolled)     and Date
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