Download This form is to be entered in WDES by authorized personnel in order...
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Attention - DO NOT enter patient data on this form if the header does not contain preprinted HALT PKD ID number, clinical center ID, and visit number.
Date of Visit:
dvm / dvd
Missing Data Codes:
B-Reading Not Possible
UNMASKING DRUG FORM
This form is to be entered in WDES by authorized personnel in order to unmask study treatment arm. The paper form is to be completed by designated personnel within 24 hours and stored in the participant’s research chart. 1.
Reason for unmasking study treatment:
Pregnancy Refer to the Manual of Procedures for guidelines requiring unmasking in the event of pregnancy.
Intercurrent Illness (Specify) uillname
Other (Explain) uoreasn
Date of last dose of study medication: _________/_______/_______ ldmm
Method of Unmasking: umeth
Date Contacted DCC _______/______/________ dccm
Other: (Specify)__________________________ 4.
Optional Section: Not Data Entered A. Treatment Arm: Study A, treat to standard BP (