Clinical Trial Early Termination Report Form
Submit detailed information regarding the early discontinuation of a clinical trial for a participant or the entire study.
Trial Information
Provide details about the clinical trial.
Trial Title
*
Protocol Number
*
Sponsor Name
*
Participant Information
Enter participant details relevant to the early termination.
Participant Study ID
*
Participant Initials
*
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Early Termination
*
-
Month
-
Day
Year
Date
Reason(s) for Early Termination
*
Adverse Event
Lack of Efficacy
Protocol Deviation
Participant Withdrawal
Lost to Follow-up
Other
Please provide details if 'Other' was selected or add any additional comments regarding the termination.
Were any serious adverse events (SAEs) or safety issues reported leading to early termination?
*
Yes
No
If yes, please describe the adverse events or safety issues.
Reporting Personnel Information
Provide your details as the person completing this report.
Full Name
*
First Name
Last Name
Role/Position
*
Email Address
*
example@example.com
Date of Report Submission
*
-
Month
-
Day
Year
Date
Signature of Reporting Personnel
*
Submit Report
Submit Report
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