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.
Participant ID:
Clinical Center:
haltid
clinic
Date of Visit:
/
/
dvm / dvd
/ dvy
visit
Missing Data Codes:
A-Participant Refused
B-Reading Not Possible
C-Institutional Error
UNMASKING DRUG FORM
Form #26
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:
rsust
Pregnancy Refer to the Manual of Procedures for guidelines requiring unmasking in the event of pregnancy.
Intercurrent Illness (Specify) uillname
Other (Explain) uoreasn
2.
Date of last dose of study medication: _________/_______/_______
ldmm
3.
Method of Unmasking: umeth
ldmd
Contacted DCC
ldmy
Date Contacted DCC _______/______/________
dccm
Other: (Specify)__________________________
4.
dccd
dccy
uometh
Comments: cmmnt
Optional Section: Not Data Entered
A. Treatment Arm:
Study A, treat to standard BP (<130/80 mm Hg)
Study A, treat to aggressive BP (<110/75 mm Hg)
Study B, treat to standard BP (<130/80 mm Hg)
B. Treatment Regimen:
Participant Received:
ACE+ placebo
ACE+ARB
*******************************************************************************************************************************************************
HALT PKD staff member completing this form:
Date: _____/_____/_____
cmidnum
Reviewed by Study Investigator (signature required):
Month cdm Day cdd
Year cdy
Date: _____/_____/_____
pism
Month pisd Day pisy Year
Data Entry Status: Please check to indicate that the above information has been entered
Primary Entered by: ____________________________________
deidnum
Date: __ __/__ __/__ __ _ __
Month
HALT PKD, Unmasked Drug, Form 26,
Version 1, 6/24/2009
Page 1 of 1
Day
Year
dem / ded / dey