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Clinical Tracking Log

Project Number : 1245.25

30/10/2014

Protocol Number:

1245.25

Sponsor:

Boehringer Ingelheim

Investigator Name:

Harbuwono, Dante Saksono

Site No.:

62002

Date

Description

Subject ID
Initials

Type

04:57 PM

Additional Comments

ID Number

09/10/2014

There were a delay in reporting the Indonesian specific


CIOMS to the EC since March 2014 and it would only be
submitted in October 2014. Reference is made to the CIOMs
cases March - October 2014 which were all reported late to
the EC.

26

The CRA will work together with the project


team and site staff to ensure the SUSAR
reporting in on time.

INVESTIGATOR'S SIGNATURE - I certify that the above information is accurate.

Investigator Signature

Date

Note:26=Non-compliance/consistent data quality issues

Page 1
Where Occured Date=2014 OCT 09 and Sponsor Site ID=Harbuwono
Clinical Tracking Log (2367) - Printed: 30/10/2014 16:57:37:.326

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