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ACRIN – V1 FORM COMPLETION INSTRUCTIONS
PREGNANCY EVALUATION FORM
V1 Completion Instructions
A V1 Form is required for each participant on study to evaluate childbearing potential.
Note: These instructions do not include all questions found on the form Please refer to the general form
completion guidelines for further instructions. Contact data management for all form related
questions/clarifications.
All available dates should be reported as MM-DD-YYYY unless otherwise specified. Code all questions unless
otherwise specified; do not leave mandatory questions blank. Please note that online logic requires dates to be no
later than current date.
1. Is the participant of childbearing potential?
1 (No) Select reason participant not of childbearing potential in Q1a, then proceed to the end of the form.
2 (Yes) Skip Q1a. Question 2 is required.
2. Was pregnancy test performed?
1 (No) Select reason pregnancy test was NOT performed Q2a, then proceed to the end of the form.
2 (Yes) Skip Q2a. Question 3 is required.
3. Date of pregnancy test:
Response required if Q2 reported as Yes. Also report result of pregnancy test in Q3a as:
3a. Result of pregnancy test:
1 (negative)
2 (positive)
V1 completion Instructions
V1.0 9/16/10
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