Form 7 Attach 1G - CTSU IBCSG Drug Accountability Form

Attach_1g_IBCSGDRG

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

Public reporting burden for this collection of information is estimated to be 5 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-xxxx). Do not return the completed form to this address.

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OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

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