You are on page 1of 40

ECG Analysis Report with Mean Comparator Change

Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947859

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 1 / DAY 15 / PRE DOSE
20-AUG-2015
10:19:00

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

24-JAN-1948
5009001

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
58

Comparator
(3 of 3)
Mean
61

Change
-3

RR Interval (ms) :

1043

985

58

PR Interval (ms) :

141

131

10

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

79

84

-5

423

406

17

417

408

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:27:06


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:27:06

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947859
COLLECTED: 20-AUG-2015

10:19:00

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947870

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 7 / DAY 15 / PRE DOSE
22-DEC-2015
09:39:40

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

24-JAN-1948
5009001

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
58

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1040

N/A

N/A

PR Interval (ms) :

141

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

71

N/A

N/A

386

N/A

N/A

381

N/A

N/A

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:18 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:26:40


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:26:40

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947870
COLLECTED: 22-DEC-2015

09:39:40

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947834

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
RUNIN CYCLE 5 / DAY 15 / 1.5 POST DOSE
17-FEB-2016
16:01:50

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

05-OCT-1939
5009003

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
66

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

911

N/A

N/A

PR Interval (ms) :

208

N/A

N/A

95

N/A

N/A

413

N/A

N/A

426

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:20 ET

Findings
Conduction:

First Degree AV Block

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:26:41


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:26:41

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947834
COLLECTED: 17-FEB-2016

16:01:50

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947844

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 2 CYCLE 2 / DAY 1 / 1.5 POST DOSE
02-FEB-2016
10:13:38

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

13-MAR-1958
5009002

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
63

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

949

N/A

N/A

PR Interval (ms) :

155

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

73

N/A

N/A

410

N/A

N/A

417

N/A

N/A

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:19 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:26:45


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:26:45

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947844
COLLECTED: 02-FEB-2016

10:13:38

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947842

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 2 CYCLE 2 / DAY 15 / PRE DOSE
16-FEB-2016
10:38:45

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

13-MAR-1958
5009002

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
68

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

884

N/A

N/A

PR Interval (ms) :

165

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

72

N/A

N/A

405

N/A

N/A

422

N/A

N/A

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:19 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:26:22


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:26:22

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947842
COLLECTED: 16-FEB-2016

10:38:45

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947864

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
UNSCHEDULED 1.5 POSTDOSE
17-SEP-2015
11:03:17

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

24-JAN-1948
5009001

Interval Duration Measurements


Sterling, Danielle
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
57

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1047

N/A

N/A

PR Interval (ms) :

151

N/A

N/A

93

N/A

N/A

408

N/A

N/A

402

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

Remarks: >> The following demography or visit name was modified from the original source ECG.
>> Please review the modified data listed above and notify ERT of any required changes
>> using the data correction instructions in your study guide.
Visit: PART 1 CYCLE 2 / DAY 21 / 1.5 POST DOSE

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:26:09


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:26:09

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947864
COLLECTED: 17-SEP-2015

11:03:17

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947837

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
RUNIN CYCLE 2 / DAY 8 / 1.5 POST DOSE
08-DEC-2015
11:58:06

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

05-OCT-1939
5009003

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
73

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

821

N/A

N/A

PR Interval (ms) :

205

N/A

N/A

98

N/A

N/A

384

N/A

N/A

410

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:20 ET

Findings
Conduction:

First Degree AV Block

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:26:08


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:26:08

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947837
COLLECTED: 08-DEC-2015

11:58:06

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947840

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 2 CYCLE 2 / DAY 15 / LEE011 4 POST
DOSE
16-FEB-2016
14:26:21

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

13-MAR-1958
5009002

Interval Duration Measurements


Thompson, Zadora
Good Tracing

Collected By:
Tracing Quality:

Comparator
Mean
N/A

Change
N/A

871

N/A

N/A

154

N/A

N/A

81

N/A

N/A

QT Interval (ms) :

424

N/A

N/A

QTc Fridericia's (ms) :

444

N/A

N/A

Lead Analyzed: II
Heart Rate (bpm) :

Mean
69

RR Interval (ms) :
PR Interval (ms) :
QRS Interval (ms) :

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:19 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:26:06


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:26:06

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947840
COLLECTED: 16-FEB-2016

14:26:21

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947862

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 2 / DAY 8 / 1.5 POST DOSE
03-SEP-2015
10:59:50

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

24-JAN-1948
5009001

Interval Duration Measurements


Thompson, Zadora
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
62

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

973

N/A

N/A

PR Interval (ms) :

144

N/A

N/A

91

N/A

N/A

400

N/A

N/A

404

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:25:48


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:25:48

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947862
COLLECTED: 03-SEP-2015

10:59:50

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947835

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
RUNIN CYCLE 3 / DAY 15 / PRE DOSE
04-JAN-2016
14:36:26

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

05-OCT-1939
5009003

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
68

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

877

N/A

N/A

PR Interval (ms) :

195

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

86

N/A

N/A

407

N/A

N/A

425

N/A

N/A

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:20 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:25:37


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:25:37

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947835
COLLECTED: 04-JAN-2016

14:36:26

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947855

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
RUNIN CYCLE 2 / DAY 8 / PRE DOSE
11-DEC-2015
11:33:14

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

13-MAR-1958
5009002

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
56

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1078

N/A

N/A

PR Interval (ms) :

191

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

73

N/A

N/A

444

N/A

N/A

433

N/A

N/A

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:19 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:25:27


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:25:27

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947855
COLLECTED: 11-DEC-2015

11:33:14

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947865

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 2 / DAY 21 / PRE DOSE
17-SEP-2015
09:30:43

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

24-JAN-1948
5009001

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
55

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1085

N/A

N/A

PR Interval (ms) :

137

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

75

N/A

N/A

422

N/A

N/A

411

N/A

N/A

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:18 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:25:35


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:25:35

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947865
COLLECTED: 17-SEP-2015

09:30:43

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947877

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 11 / DAY 15 / 1.5 POST DOSE
10-MAR-2016
13:03:23

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

24-JAN-1948
5009001

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
60

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1004

N/A

N/A

PR Interval (ms) :

147

N/A

N/A

76

N/A

N/A

415

N/A

N/A

415

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:25:14


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:25:14

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947877
COLLECTED: 10-MAR-2016

13:03:23

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947847

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 2 CYCLE 1 / DAY 21 / LEE011_PRE
DOSE
27-JAN-2016
10:15:24

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

13-MAR-1958
5009002

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
57

RR Interval (ms) :
PR Interval (ms) :

Comparator
(3 of 3)
Mean
66

Change
-9

1047

913

134

175

177

-2

75

82

-7

QT Interval (ms) :

415

432

-17

QTc Fridericia's (ms) :

408

445

-37

QRS Interval (ms) :

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:19 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:25:03


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:25:03

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947847
COLLECTED: 27-JAN-2016

10:15:24

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947869

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 5 / DAY 15 / 1.5 POST DOSE
19-NOV-2015
13:58:53

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

24-JAN-1948
5009001

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
59

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1013

N/A

N/A

PR Interval (ms) :

140

N/A

N/A

76

N/A

N/A

393

N/A

N/A

392

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:24:48


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:24:48

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947869
COLLECTED: 19-NOV-2015

13:58:53

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947857

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
RUNIN CYCLE 1 / DAY 15 / 1.5 POST DOSE
25-NOV-2015
16:15:17

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

13-MAR-1958
5009002

Interval Duration Measurements


Thompson, Zadora
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
60

Comparator
(3 of 3)
Mean
63

Change
-3

RR Interval (ms) :

992

948

44

PR Interval (ms) :

174

170

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

81

86

-5

433

420

13

434

427

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:19 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:24:45


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:24:45

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947857
COLLECTED: 25-NOV-2015

16:15:17

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947876

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 11 / DAY 15 / PREDOSE
10-MAR-2016
11:32:19

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

24-JAN-1948
5009001

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
65

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

917

N/A

N/A

PR Interval (ms) :

139

N/A

N/A

83

N/A

N/A

404

N/A

N/A

416

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:24:32


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:24:32

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947876
COLLECTED: 10-MAR-2016

11:32:19

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947839

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 2 END OF TREAMTENT
01-MAR-2016
11:04:19

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

13-MAR-1958
5009002

Interval Duration Measurements


Warren, Dominic
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
70

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

861

N/A

N/A

PR Interval (ms) :

166

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

75

N/A

N/A

417

N/A

N/A

439

N/A

N/A

Evaluation
Interpretation:

Normal

Evaluation By:
Evaluation Date/Time:

For Site Use Only.


Investigator Signature: __________________________________________________

Muhammad Iqbal
07-JUL-2016 17:19 ET

Date: ____________________________

Generated on: 07-JUL-2016 17:24:27


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:24:27

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947839
COLLECTED: 01-MAR-2016

11:04:19

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947871

Subject Information
5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
PART 1 CYCLE 9 / DAY 15 / 1.5 POST DOSE
04-FEB-2016
12:30:15

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

Date of Birth:
7 Digit Subject Number:

24-JAN-1948
5009001

Interval Duration Measurements


Sterling, Danielle
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
56

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1067

N/A

N/A

PR Interval (ms) :

147

N/A

N/A

85

N/A

N/A

418

N/A

N/A

409

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

Remarks: >> The following demography or visit name was modified from the original source ECG.
>> Please review the modified data listed above and notify ERT of any required changes
>> using the data correction instructions in your study guide.
Visit: PART 1 CYCLE 9 / DAY 15 / PRE DOSE

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:24:15


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:24:15

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947871
COLLECTED: 04-FEB-2016

12:30:15

Page 2 of 2

ECG Analysis Report with Mean Comparator Change


Sponsor:
Protocol:
Account:
Transmittal Number:

Array BioPharma Inc.


CLGX818X2109
746874
12947878

Subject Information
Date of Birth:
7 Digit Subject Number:

5009
Chmielowski, Bartosz
924 Westwood Blvd.
Suite 200
Los Angeles CA 90024
United States of America
UNSCHEDULED PREDOSE
05-AUG-2015
08:49:32

Site ID:
Investigator Name:
Address:

Visit:
Collection Date:
Collection Time:

24-JAN-1948
5009001

Interval Duration Measurements


Sterling, Danielle
Good Tracing

Collected By:
Tracing Quality:
Lead Analyzed: II
Heart Rate (bpm) :

Mean
57

Comparator
Mean
N/A

Change
N/A

RR Interval (ms) :

1048

N/A

N/A

PR Interval (ms) :

143

N/A

N/A

77

N/A

N/A

395

N/A

N/A

389

N/A

N/A

QRS Interval (ms) :


QT Interval (ms) :
QTc Fridericia's (ms) :

Evaluation
Interpretation:

Abnormal

Evaluation By:
Evaluation Date/Time:

Muhammad Iqbal
07-JUL-2016 17:18 ET

Findings
Conduction:

Left Anterior Hemiblock

Remarks: >> The following demography or visit name was modified from the original source ECG.
>> Please review the modified data listed above and notify ERT of any required changes
>> using the data correction instructions in your study guide.
Visit: PART 1 CYCLE 1 / DAY 1 / PRE DOSE A

For Site Use Only.


Investigator Signature: __________________________________________________

Date: ____________________________

Generated on: 07-JUL-2016 17:24:00


1818 Market Street
Philadelphia, PA 19103
United States of America

Page 1 of 2
Peterborough Business Park
Lynch Wood
Peterborough, Cambridgeshire PE2 6FZ

PROTOCOL:

Array BioPharma Inc. - CLGX818X2109

SITE:

5009

INVESTIGATOR: Chmielowski, Bartosz

Generated on: 07-JUL-2016 17:24:00

ERT

ACCOUNT: 746874

TRANSMITTAL: 12947878
COLLECTED: 05-AUG-2015

08:49:32

Page 2 of 2

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