Form 1 DARF

Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0240). Do not return the completed form to this address.

Division of Cancer Treatment and Diagnosis
Cancer Therapy Evaluation Program

National Institutes of Health
National Cancer Institute

OMB No. 0925-0240
Expires: 11/30/2007
NIH-2564

PAGE NO.

SATELLITE RECORD …
CONTROL RECORD

Investigational Agent Accountability Record
Name of Institution:

NCI Protocol No.:

Agent Name:

Dose Form and Strength:

Protocol Title:

Dispensing Area:

Investigator Name:

NCI Investigator No.:

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No.

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Date

Patient’s
Initials

Patient’s ID No.

Dose

Quantity
Dispensed or
Received

Balance Forward
Balance

Manufacturer
and Lot No.

Recorder’s
Initials