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richard-smiraldi
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MEAL SCHEDULE
MEAL
M M
24 HR. CLOCK
H H
M M
24 HR. CLOCK
H H
WAS THE MEALADMINISTERED?
(MARK ONE)
D D M M M Y Y
DATE OF MEAL
MEAL SCHEDULE
MEAL
D D M M M Y Y
DATE OF MEAL
HIGH-FAT
RELATIVETIME
AM
START TIMESTOP TIME
WAS THE MEALCOMPLETED?(MARK ONE)
0 NO 1 YES0 NO 1 YES
WAS THE MEALADMINISTERED?
(MARK ONE)
0 NO 1 YES M M
24 HR. CLOCK
H H
M M
24 HR. CLOCK
H H
START TIMESTOP TIME
WAS THE MEALCOMPLETED?(MARK ONE)
0 NO 1 YES
WAS A NEW STUDY MEDICATION KIT DISPENSED?
KIT NUMBER DISPENSED AT THIS VISIT:
DATE AND TIME OF DOSE TAKEN AT THIS VISIT:
DATE TIME NUMBER TAKEN PER BOTTLE
BOTTLE A BOTTLE B
STUDY MEDICATION
D D M M M Y Y M M
24 HR. CLOCK
H H
0 NO 1 YES
SMED
DISP006
OTHER TREATMENT
D D M M M Y Y M M
24 HR. CLOCK
H HRITONAVIR 200 mg
0 NO 1 YESIS THE SUBJECT IN DOSE GROUP 2? IF YES, COMPLETE BELOW
TREATMENT DATE OF DOSE TIME OF DOSEWAS DOSE ADMINISTERED?
0 NO 1 YES
DOSING - DAY 1
DAY
1
START DATE OF INFUSION
D D M M M Y Y
STOP DATE OF INFUSIONSTART TIME OF INFUSION STOP TIME OF INFUSION
mg
TOTAL DOSE DELIVERED
M M
24 HR. CLOCK
H H M M
24 HR. CLOCK
H H
DOSING CHANGES
WAS DOSE OMITTED?
WAS THE INFUSION TEMPORARILY INTERRUPTED?INTERRUPTION DURATION:
1 MIN 2 HR
DOSE OMITTED REASONS
9 = DELAYED HEMATOLOGIC RECOVERY12 = DELAYED NON-HEMATOLOGIC RECOVERY (SPECIFY)98 = OTHER (SPECIFY)
INFUSION INTERRUPTED REASONS8 = HYPERSENSITIVITY REACTION
17 = ADVERSE EVENT (SPECIFY)98 = OTHER (SPECIFY)
REASON SPECIFY0 1
NO
YES
DAY
1
g
WEIGHT OFINFUSATE DELIVERED
SITE OF INFUSION:1 LEFT ARM 2 RIGHT ARM
3 CENTRAL LINE 98 OTHER (SPECIFY)
D D M M M Y Y
RECORD OF STUDY MEDICATION
D D M M M Y Y M M
24 HR. CLOCK
H H
A B C
TREATMENT DATE OF DOSE TIME OF DOSE
WAS THE DOSE ADMINISTERED? 0 NO 1 YES
RECORD OF STUDY MEDICATION
DOSE GROUP DATE OF DOSE TIME OF DOSE(MARK ONE)
D D M M M Y Y M M
24 HR. CLOCK
H H
1 2 3
4 5 6
WAS THE DOSE ADMINISTERED? 0 NO 1 YES
RECORD OF STUDY MEDICATION
D D M M M Y Y M M
24 HR. CLOCK
H H
BMS-298585 10 mg
TREATMENT TIME OF DOSEDATE OF DOSE
RECORD OF STUDY MEDICATION
TREATMENT DATE OF DOSE TIME OF DOSE
D D M M M Y Y M M
24 HR. CLOCK
H H
WAS THE DOSE ADMINISTERED? 0 NO 1 YES
RECORD OF STUDY MEDICATION
D D M M M Y Y M M
24 HR. CLOCK
H H
WAS THE DOSE ADMINISTERED?
0 NO 1 YES
DATE OF DOSE TIME OF DOSE
DRUG ADMINISTRATION
D D M M M Y Y M M
24 HR. CLOCK
H H M M
24 HR. CLOCK
H H
A B
0 NO 1 YES
WAS THE DOSE ADMINISTERED? 0 NO 1 YES
TREATMENTSTART TIMEOF INFUSION
STOP TIMEOF INFUSION
DATE ADMINISTERED?
WAS FULL INFUSION COMPLETED?
TOTAL DOSE ADMINISTERED? mg