Cytokine Release Syndrome Incidence Tracker Form
Document and monitor clinical details for each CRS event. Please complete all relevant fields for accurate tracking.
Event Tracking ID (non-sensitive, e.g., study or site code + number)
*
Date and Time of CRS Event Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient or Subject Study Identifier (do not use name or MRN)
*
CRS Severity Grade (per standard criteria)
*
Grade 1 (mild)
Grade 2 (moderate)
Grade 3 (severe)
Grade 4 (life-threatening)
Symptoms Observed (select all that apply)
*
Fever
Hypotension
Hypoxia
Tachycardia
Organ dysfunction
Other
Time from Therapy/Trigger to CRS Onset (in hours)
Interventions/Management Provided
Antipyretics
IV fluids
Vasopressors
Oxygen therapy
Tocilizumab
Corticosteroids
Other
Outcome of CRS Event
*
Resolved without sequelae
Resolved with sequelae
Ongoing
Fatal
Time to CRS Resolution (in hours)
Reviewer or Clinician Initials
*
Submit Event
Should be Empty: