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On-Site Data Clarification Form

Protocol ID: IOLf Subject Identification

Number
f0ttG30IOOJ Subject Initials: r --
Site PI Name: d.r - Wrw14 )rswi, JWe-, C,. {¥) 1 JL ~ r;,d' ODCF Issuer Name: 1,µ- -~ ~tlllane>..

CRF Page/ Item/Field CRF Data

Resolution or New Value
Reoeat No. Descriotion Oriainal Entrv/Data Discreoancv

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I approve these SOW clarifications and/or corrections. I will maintain a copy of this data clarification form w ith the SOW.

Site PI or Co-PI Signature:

~ Date: OJ / Jut... / 2..0, !)

Scan Copy - DMS at I NA-RESPOND Secretariat Original - Site

F-INA-025.0 1 On-Site Data Clarificat ion Form Effective Date: 10 Oct 2016
I NA104 v2. 0 - date effective 14 May 2019
Page 1 of 1
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