HEADER: PI NAME, Protocol or IRB Number, Protocol Short Title

Subject Initials Subject ID

Electrocardiogram Results

Date: / / Electrocardiogram not

performed
Month Day Year

Time:
: (using 24 hour format)
(e.g. hh:mm)

Visit Number (check one):

Visit # Visit # Visit #
Visit # Visit # Visit #
Visit # Visit # Visit #

Position of Subject: Sitting Supine

ECG Measurement/Result
(check one) (check one)
Heart Rate bpm Normal Abnormal Clinically significant? Yes No

PR Interval msec Normal Abnormal Clinically significant? Yes No

QRS Duration msec Normal Abnormal Clinically significant? Yes No

QTc Interval msec Normal Abnormal Clinically significant? Yes No

Cardiac Rhythm: (check one)

Normal Sinus Rhythm
Atrial Fibrillation
First–degree AV Block
Ventricular Tachycardia
Sinus Bradycardia
Atrial Flutter Sinus Tachycardia
Type I Second Degree AV Block SupraVentricular Tachycardia
Type II Second Degree AV Block Third Degree AV Block
Ventricular Fibrillation Paced Rhythm
Other: (specify) Other: (specify)

Overall assessment Normal Abnormal Clinically significant? Yes No

ECG done by:

ECG read by:

Form Number: Version Date: 01/31/2016 Page 1 of 1

Comment(s):

Form Number: Version Date: 01/31/2016 Page 1 of 1