Elfin Form 02 - Infant Daily Dosing Log (34 Postmenstrual Weeks Of Age)
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1
2ELFIN study number:
ELFIN study number:
If any doses not given, please explain why:
Form 2: Daily Dosing
Use this form:
Once infant reaches 12 ml/kg/day milk feeds
Details of person completing form
Until infant reaches 34 postmenstrual weeks of age
Name
Role
/
/
Date
D
D
M
M
Y Y
Signature
Use a new form for each pack of IMP
Definitions
Parenteral nutrition (PN): solutions containing a mix of essential and non-essential amino acids,
glucose, fat, electrolytes and micronutrients
Suspected NEC: sufficient concern about the abdomen that feeds are stopped or withheld for
more than 4 hours
Infant’s surname
Infant’s first name
For URGENT queries outside office hours telephone 0800 138 5451 and leave a message with the
/
/
Date of birth
D
D
M
M
Y Y
operator. You will be called back.
Name of hospital where this form was completed
Contact Details
Please record the details of the ELFIN treatment pack documented on this dosing log:
NPEU Clinical Trials Unit
Treatment packs should be used in the order allocated. A new pack should not be started until
the previous pack is completed.
National Perinatal Epidemiology Unit
Date allocated
Pack ID number
University of Oxford
Old Road Campus
/
/
Pack
D
D
M
M
Y Y
Oxford
OX3 7LF
01865 289 740
01865 289 741
elfin@npeu.ox.ac.uk
Only for NPEU office use
Date
Initials
/
/
Logged
D
D
M
M
Y Y
/
/
1st entry
D
D
M
M
Y Y
/
/
2nd entry
D
D
M
M
Y Y
ELFIN Form 2: Daily Dosing
Version 2.0, 18 August 2015
Page 4 of 4
ELFIN Form 2: Daily Dosing
Version 2.0, 18 August 2015
Page 1 of 4
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