INVESTIGATIONAL DRUG ACCOUNTABILITY RECORD

Sponsor Name :							Protocol No:
Investigator  :							Total Quantity Received/Date         : (including Replacement kits)
Center code :  N/A							Test Drug:
Study site Name :							Batch No.    :  Batch No.    :
							Mfg Date     :  Mfg Date     :
							Expiry Date :  Expiry Date :
Study Title
Subject initials	Subject ID	Drug Kit Number	Visit	Date dispensed	Dispensed By/Initials	Date Returned		Amount of Drug present	Site personnel Signature	CRA/Monitor Signature