Monitor Visit Log 4 February 2011 by HboOlYG7

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									                                                            MONITOR VISIT LOG
                                                                                                 To be completed at each monitor visit

Gerald Bronfman Centre for Clinical Research in Oncology                             HOSPITAL: JGH      MGH        RVH       SMH
Clinical Research Program

Protocol #: _______________/ McG (NCIC) __________         Sponsor: ________________             Study Coordinator Name: ___________________

  DATE         PATIENT      PATIENT     SCREENING/     COURSE/VISIT     F/UP VISIT     QUERIES                  COMMENTS
MONITORED      STUDY ID     INITIALS     BASELINE        NUMBER          NUMBER         ONLY




_________________________________          ___________________________________                ___________________
Monitor: Print Name                                      Signature                                    Date                      Page __ / __
                                                                                                                             version: 04-Feb-2011
                                                               MONITOR VISIT LOG
INSTRUCTIONS:

Monitors are required to complete the Monitor Log confirming the following information monitored at the visit. Information included in the
on the log will translate into invoices to the sponsor. Information provided must be accurate.

              - No more than one study per log to be completed.
              - Patient initials and study number
              - Cycles and/or follow-up visits monitored. Please include the cycle and/or visit number: i.e, C1, V3, Wk13, etc.
              - If only queries are being addressed, please include the number of queries for each patient.
              - Any additional information that is pertinent to the patient can be added in the Comments Section.
              - Print, sign and date the form. The original must be provided to the Study Coordinator at the end of each visit.
MONITOR VISIT LOG
                    version: 01-Nov-2010

								
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