CRF TRANSMITTAL FORM

Amgen Red HF Study

Protocol/Study Number: 20050222

Site Number:

Patient Number:

Submitted By:

Date: (dd/mmm/yyyy)

Instructions for submission:

Courier & Tracking Number:

Quintiles use only:

Original white copy of CRF page is to be sent to Data Management with copy retained at the site.
Attach a separate CRF transmittal form for each subject
PEP CRF pages should be submitted as soon as a PEP number is received
Header information and page numbers should be closely reviewed for accuracy prior to submission!

Indicate below the CRF pages submitted per subject. Place a tick in the Tick column if all CRF pages within a section are being submitted
together. If individual pages are being submitted circle the applicable pages below.
Visit
Screening
Wk 1-13
Wk 15-27
Wk 29-39
Wk 41-53
Wk 55-65
Wk 67-77
Wk 79-91
Wk 93-105
Wk 107-117
Wk 119-131
Wk 133-147
Wk 149-157
Wk 159-169
Wk 171-183
Wk 185-195
Wk 197-209
Wk 211-221
Wk 223-235
Wk 237-247

Page numbers
0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09
1.01 1.02 1.03 1.04 1.05 1.06 1.07
2.01 2.02 2.03 2.04 2.05 2.06 2.07
3.01 3.02 3.03 3.04 3.05 3.06 3.07
4.01 4.02 4.03 4.04 4.05 4.06 4.07
5.01 5.02 5.03 5.04 5.05 5.06 5.07
6.01 6.02 6.03 6.04 6.05 6.06 6.07
7.01 7.02 7.03 7.04 7.05 7.06 7.07
8.01 8.02 8.03 8.04 8.05 8.06 8.07
9.01 9.02 9.03 9.04 9.05 9.06 9.07
10.01 10.02 10.03 10.04 10.05 10.06 10.07
11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08
23.01 23.02 23.03 23.04 23.05 23.06
24.01 24.02 24.03 24.04 24.05 24.06
25.01 25.02 25.03 25.04 25.05 25.06
26.01 26.02 26.03 26.04 26.05 26.06
27.01 27.02 27.03 27.04 27.05 27.06
28.01 28.02 28.03 28.04 28.05 28.06
29.01 29.02 29.03 29.04 29.05 29.06
30.01 30.02 30.03 30.04 30.05 30.06

Tick

Visit
EOT
TRAN/AF
EOS
COMM
CURR
INV VER
PRO Wk 1
PRO M3
PRO M6
PRO M9
PRO M12
PRO M18
PRO M24
PRO M30
PRO M36
PRO M42
PRO M48
PRO M54
PRO EOS
PEPs

Page numbers
12.01 12.02 12.03 12.04
13.01 14.01
15.01 15.02 15.03 15.04 15.05 15.06
16.01 16.02 16.03
110
17.01 (only to be submitted at study completion)
100 101 102 103 104 105 106 107 108
200 201 202 203 204 205 206
300 301 302 303 304 305 306 307 308
400 401 402 403 404 405 406
500 501 502 503 504 505 506 507 508
600 601 602 603 604 605 606 607 608
700 701 702 703 704 705 706 707 708
800 801 802 803 804 805 806 807 808
1000 1001 1002 1003 1004 1005 1006 1007 1008
1100 1101 1102 1103 1104 1105 1106 1107 1108
1200 1201 1202 1203 1204 1205 1206 1207 1208
1300 1301 1302 1303 1304 1305 1306 1307 1308
900 901 902 903 904 905 906
21. __ __ 21. __ ___

Did this subject terminate from the study prior to completing all visits (please circle)? Yes / No

Tick