Form 8 CTSU IBCSG Drug Accountability Form

Attachment_1h_ibcsgdrug
Attach_1g_IBCSGDRG

OMB#0925-0624
Expiration Date: 12/31/2013

Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including
the time for
reviewing
instructions,
existing
data sources,
gathering
andper
maintaining
Public reporting
burden
for this
collection searching
of information
is estimated
to be
5 minutes
response,the data
needed,
and
completing
and
reviewing
the
collection
of
information.
An
agency
may
not
conduct
sponsor, and
including the time for reviewing instructions, searching existing data sources, gathering and or
maintaining
the data
a person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and
control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
a person is not required to respond to, a collection of information unless it displays a currently valid OMB
including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
Bethesda, MD 20892-7974, ATTN: PRA (0925-0624). Do not return the completed form to this address.
including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-0624). Do not return the completed form to this address.

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OMB#0925-0624
Expiration Date: 12/31/2013

Attachment_1h_ibcsgdrug
Attach_1g_IBCSGDRG

1441 West Montgomery Ave WB 410S Rockville, MD 20850-2062 1-888-823-5923 FAX 1-888-691-8039

Page#:
Primary Pharmacy Record
Satellite Pharmacy Record
NCI Institution Code:

IBCSG Drug Accountability Form
North American Sites
Name of Institution:
Dispensing Area:
Agent Name:
Investigator Name:
Line
#

Date
(mm/dd/yy)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Draft8_04CTSU

Dose Form & Strength:
NCI Investigator #:
Protocol #

Pt.
initials

Pt. ID#

Treatment Dose
Arm

Quantity Balance
dispensed Forward
or
received

Manufacturer Recorder’s
& Lot #
Initials