Study Drug Accountability Log

Name of Drug: _____________________________

Protocol Number:
Subject’s Initials _____________
Accession Number _____________

Lot Number Date Number of Date Drug Number of Study *Date sent to Study Comments
Dispensed tablets/vials Returned tablets/vials Coordinator Investigational Coordinator
to patient Dispensed Returned Initials Pharmacy Initials

__________________________ ______ __________________________ ______

Signature Initials Signature Initials
__________________________ ______ __________________________ ______
Signature Initials Signature Initials