Patient number

Data collection sheet

1. Patient data
i. Patient's name: ……………………………………………

ii. Patient's number:

Home number

iii. Gender: male

Female

iv. Date of birth: ……………/…………………/………………….

v. Weight: ………………… height:………………………

vi. Naive experienced

vii. District: ……………………………………………………………………

2. Primary Efficacy End Points

Weeks Week 4 Week 8 Week 12 Week 16 Week 20 Week 24

(RVR ) (SVR)

PCR
 3. Primary Safety End Point

Weeks Week 4 Week 8 Week 12 Week 16 Week 20 Week 24

ALT

AST

Bilirubin

ANC

Platelets

HB

WBC

INR

Serum
creatinine

Urea

Albumin

Alpha-
fetoprotein

Weeks Week 4 Week 8 Week 12 Week 16 Week 20 Week 24

 Yes No Yes No Yes No Yes No Yes No Yes No
SAEs

Anemia

Hepato-renal
syndrome

Hepatic
toxicity

Cirrhosis

Arrhythmia

Ascites

Hepatocellula
r carcinoma

Esophageal
varices