Echocardiogram or MUGA

*The timeline requirements for this form are as follows:
Assessment Time Frame: Screening occurs up to 45 days prior to the anticipated start of the conditioning regimen. May be performed earlier than 45 days prior to the start of the conditioning regimen.
Submission Time Frame: Within 5 business days of collection.

Date of most recent echocardiogram or multiple-gated acquisition scan (MUGA):
Enter the date of most recent echocardiogram or multiple gated acquisition scan (MUGA). Date can either be entered directly in the data field using the DD/MMM/YYYY format, or the calendar date picker can be used.

Per protocol an echocardiogram or MUGA scan is required at Screening. If this field is marked as “Intentionally Left Blank” a protocol deviation should be logged in the EDC.

If the date entered is a future date, a query will appear in the EDC.

LVEF:
Report the subject’s LVEF (left ventricular ejection fraction) in %. This field allows up to four characters.

CCG v1.0 | CRF v1.3

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