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  • Websend Data Change Request Form Ischemia - Ccta Core Lab: (Please Provide An Excel Report or Screenshot From Webview)

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    Surendra Yadav
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    This document is a data change request form for a clinical trial participant. It requests changing the timepoint from "656002-001" to "Enrolled Patient" for a participant at a site. The reason given is that the site uploaded an enrolled patient with the incorrect "Site Certification" timepoint. The form provides contact information for the requestor and the person at BioClinica who completed the request.

    Original Description:

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    Original Title

    20140707_WO#INC0057256_Site 656002-001

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    This document is a data change request form for a clinical trial participant. It requests changing the timepoint from "656002-001" to "Enrolled Patient" for a participant at a site. The reason given is that the site uploaded an enrolled patient with the incorrect "Site Certification" timepoint. The form provides contact information for the requestor and the person at BioClinica who completed the request.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    13 views2 pages

    Websend Data Change Request Form Ischemia - Ccta Core Lab: (Please Provide An Excel Report or Screenshot From Webview)

    Uploaded by

    Surendra Yadav
    This document is a data change request form for a clinical trial participant. It requests changing the timepoint from "656002-001" to "Enrolled Patient" for a participant at a site. The reason given is that the site uploaded an enrolled patient with the incorrect "Site Certification" timepoint. The form provides contact information for the requestor and the person at BioClinica who completed the request.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    Websend Data Change Request Form

    ISCHEMIA - CCTA CORE LAB


    Date Requested: __7/7/2014___ Work Order #: INC0057256
    Sponsor: NYU Site ID Subject ID: ___656002-001_
    Protocol #: 39601___________________ Sites Telephone #: _____________________

    Data Point: Timepoint

    Current 656002-001
    Value in
    system:
    (Please
    provide an
    Excel Report
    or screenshot
    from
    Webview)

    Value to be Please change timepoint to Enrolled Patient


    updated to:
    Reason for Site uploaded an enrolled patient with a Site Certification timepoint.
    Change:
    Approvals:

    Requested By: Title: Date:


    Niree Hindoyan Research Support Assistant 7/7/2014

    _______________________________________________________________________________ _

    Approvals Needing Sponsor Authorization:

    Sponsor Approval (name): Title: Date:

    Please fax/email the completed form to BioClinica HelpDesk:


    Fax: (267) 685-1176
    Email: helpdesk@bioclinica.com
    BioClinica WebSend Use Only_- Request Completed

    BioClinica WebSend Contact Title: Date:

    Vinay Korgaonkar Application Support Engineer 07 Jul 2014

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