Participant Medical Device Accountability Log

Protocol #:	________________________________	Principal Investigator:	_______________________________
Participant #:	________________________________	Site ID:	_______________________________
Participant initials:	________________________________	Storage Location	_______________________________
Usage/Dispensing information	Dispensed by
Investigational Device	Lot/Batch number	Visit #	Date Dispensed	Time Dispensed	Quantity Dispensed	Name	Signature/Initials	Comments