Header
PI Name
text
Protocol or IRB Number
integer
Protocol Short Title
Subject Initials
Subject ID
Number of Page
Total Number of Pages
Adverse Event Tracking Log
#
Date Reported
date
Adverse Event Description
Adverse Event Category
Start Date
End Date
0= Fatal 1= Not recovered/not resolved 2= Recovered w/sequelae 3= Recovered w/o sequelae 4= Recovering/Resolving
1= Mild 2= Moderate 3= Severe 4= Life threatening 5= Fatal
Serious
boolean
Expected
0= None 1= Medication(s) 2= Non-medication TX
0= None 1= Interrupted 2= Discontinued 3= Dose reduced 4= Dose increased 5= Not Applicable
0= Definite 1= Probable 2= Unlikely 3= Unrelated
PI Initials
Date of PI Initials