12.1
Did the patient complete the study?
12.1.1
Reason for premature discontinuation of the trial:
Only shown if field 12.1 is equal to No
12.2
Date of last contact with the patient for this study
By signing and dating this page for the study and patient identified above, I declare that the information on this and all other pages of the Case Report Form has been reviewed by me or m y delegate, and is accurate and complete.
12.3
Signed by (Principal) Investigator
NoYes
0: No
1: Yes
ReasonPrematurrDiscontinuation
1: Lost to follow up
2: Withdrawal of consent
3: Non compliant
4: (Serious) adverse event
5: Screening failure
6: Other
Signed
1: Signed