Clinical Event Adjudication Form
Review and classify reported clinical events for adjudication purposes.
Reviewer Name
*
First Name
Last Name
Date of Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Reference Number
*
Event Type
*
Please Select
Adverse Event
Serious Adverse Event
Protocol Deviation
Other
Event Classification
*
Related
Not Related
Uncertain
Severity Assessment
*
1
2
3
4
5
Was the event expected based on protocol or prior data?
*
Yes
No
Review Criteria Assessment
*
Rows
Not Met
Partially Met
Fully Met
Documentation Completeness
1
2
3
Consistency with Protocol
4
5
6
Clarity of Event Description
7
8
9
Overall Confidence in Classification
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Additional Comments or Recommendations
Submit
Should be Empty: