Download Investigational Drug Information Form

INVESTIGATIONAL DRUG INFORMATION FORM
Note: this form is to be filled for any drug that will undergo a clinical study/trial. The investigator
will supply the Pharmacy with the drug to be dispensed. The drug will be dispensed only upon receipt
of a prescription by authorized investigators.
A copy of the protocol and a signed, approved informed consent must be attached to the patient's chart
before administration of drug.
Generic name:
Chemical name:
Trade name:
Manufacturer:
Primary actions of drug (by category):
How supplied (Form and unit dose):
Mode of administration:
Carriers and preservatives:
Cautions:
Proposed Therapeutic Use:
Dose (Amt/kg/day and schedule):
Usual Side effects:
Antidotes (per category of drug's primary action):
Attach information on drug (reports, bibliography):
Pharmacology
Toxicology and evaluation of side effects
Experience to date in analogous usage
Has this drug been approved by the Federal Drug Administration (FDA) of U.S.A.?
If not, what is its Investigational New Drug (IND) number?
IND number:
Assignee:
N/A
Yes
No
Has the FDA placed any restrictions on the use of the drug?
Yes
No. If yes, please explain.
Designate the place and person the patient should go to and contact should any adverse effects result.
Authorized users:
Principal investigator:
Others:
Will nursing staff be authorized to administer the drug?
If yes, a physician must be within reasonable proximity.
(Note: Authorization does not commit nursing staff to do so.)
Yes
No