Electronic Case Report Form

An Electronic case report form is the digital or computerized format of a paper form. The purpose of electronic report form is to keep the data secure and updated for long term. However, it is necessary to follow the regulations and instructions of related organization while preparing an electronic case report form.

Sample Electronic Case Report Form

General Information

Name of Clinic/Pharmacy Company__________ Registration Number___________

Address__________ Phone____________ Email___________
Person making report____________ Designation___________ Phone________

Case Title___________

Case Report Information

Case Nature: Medicine Trial/Experiment/Lab research__________

Date of Case Commencement__/___/___

End Date of Case__/___/___

Total Duration of Case________

Case Supervisor Name___________

Purpose of Case_________________

Description of Case________________________

Test/Experiments have been done during case duration___________________________

____________________________

Equipments/Research Methods used in case study_________________________________

______________________________

Assistants/Experts associated with this case______________________

Results of Case_________________________

Analysis of Case________________________

Total Cost of Case_______________________

Signature_________________   Date of report Submission__/___/___

Case Report Confirmation Information

Case Report Status: ____________

Recipients Name_________ Designation___________ Signature____________

Date of Approval___/___/___

Submit/Reset/Start_____________

Category: Report Forms