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04/05/2004 11:05
22/04/2004 12:03
49-931-20136759
NCPL + 9004993120136283
DIABETESAMBULANZ
S. 02/03
NO. 638 0003
PROactive
Urgent Data Enquiry Form
Barcode graphic
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Centre number
49013 |
Patient number
014 |
Patient initials
- |
Date of randomisation
05-11-01 |
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Reference
135037-hrt-11 |
Date issued
22-04-04 |
Date resolved | |
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17 Alert Report Booklet A15778 (page 001) -04, Benign tumor of the urinary bla
ITEM 07: Medical event (diagnosis) For all serious episodes of Bladder cancer, Takeda Drug Safety require additional information and would appreciate it if you could complete the attached questionnaire and return it to us with this enquiry form signed and dated as soon as possible. Reply: It was no cancer, if it was a benign tumor (see the diagnosis of the above report) |
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Signature:
C Beds |
Date:
4/5/04 |
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| Please write your reply in the space provided and ensure that the reply is signed as this sheet will become part of the patient's record form. Once completed, please fax the form back to the Study Coordinating Centre (++44 115 956 77 22) and retain the original in the patient's Case Report Form. | |||
Confidential – Subject to Protective Order
TAK-INDNDA-00456053
Produced in MDL on 09/12/12
Source: https://www.industrydocuments.ucsf.edu/docs/rljf0226
P0026-00003