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       <span style="font-family:Times New Roman;font-size:22pt;">DELEGATION OF RESPONSIBILITY LOG</span>
      </div> </td> 
    </tr> 
    <tr style=" height:22pt; "> 
     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 114.60pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Protocol Number</span>
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">:</span>
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     <td colspan="6" style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right:dotted 1px #ffffff;width: 383.45pt; "> <a name="bm_Text1"></a>
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       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">     </span>
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    <tr style=" height:22pt; "> 
     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 114.60pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Site Name </span>
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     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 13.50pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">:</span>
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     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 192.05pt; "> <a name="bm_Text2"></a>
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       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">     </span>
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     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 70.50pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Site Number</span>
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       <span style="font-family:Times New Roman;font-size:11pt;">:</span>
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     <td colspan="2" style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right:dotted 1px #ffffff;width: 106.65pt; "> <a name="bm_Text5"></a>
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       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">     </span>
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Principal Investigator</span>
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     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 192.05pt; "> <a name="bm_Text3"></a>
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       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">     </span>
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       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
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     <td colspan="2" style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 14.25pt; "> 
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       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
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     <td colspan="2" style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 106.65pt; "> 
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       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
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    <tr style=" height:22pt; "> 
     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 114.60pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;">Sponsor</span>
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     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 13.50pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">:</span>
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     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 192.05pt; "> <a name="bm_Text4"></a>
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       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">     </span>
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     <td colspan="2" style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 70.85pt; "> 
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       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
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     <td colspan="2" style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 14.20pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 106.35pt; "> 
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       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
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   <tbody>
    <tr style=" height:11.60pt; "> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 113.45pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Name</span>
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     <td colspan="2" style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Role </span>
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     <td colspan="3" style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 134.70pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Key Study Task(s) &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">(choose from list below)</span>
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     <td colspan="2" style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 43.25pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Initials</span>
      </div> </td> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Signature</span>
      </div> </td> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Start Date </span>
       <span style="font-family:Times New Roman;font-size:8pt;font-weight:bold;">(dd/mmm/yyyy)</span>
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     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 42.55pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">PI Initial</span>
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     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 70.85pt; "> 
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       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">End Date </span>
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       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:8pt;font-weight:bold;">(dd/mmm/yyyy)</span>
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       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">(If prior to EOS)</span>
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     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">PI Initial</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 113.45pt; "> <a name="bm_Text6"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">Principal Investigator</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> <a name="bm_Text7"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> <a name="bm_Text14"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
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       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> <a name="bm_Text8"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> <a name="bm_Text15"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 113.45pt; "> <a name="bm_Text9"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 106.30pt; "> <a name="bm_Text23"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f2f2f2; width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td colspan="7" style=" border-right-color:#000000;border-left:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 354.75pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Investigator Signature:</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Comments:</span>
      </div> </td> 
     <td colspan="6" style=" border-left-color:#000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 392.05pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Date:</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:64.50pt; "> 
     <td colspan="2" style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 174.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">Task Key:</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">1 = Obtain Informed Consent</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">2 = Subject selection/recruitment </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">3 = Confirm eligibility (review inclusion/exclusion criteria) </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">4 = Obtain medical history (source documents) </span>
      </div> </td> 
     <td colspan="2" style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 173.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">5 = Perform physical exam</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">6 = Conduct study visit procedure as outlined in the protocol &nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">7 = Make study related medical decisions</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">8 = Assess AEs/SAEs </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">9 = Dispense study drug</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="5" style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 176.95pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">10 = Perform drug accountability &nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">11 = Study drug storage and temperature monitoring</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">12 = Sample collection</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">13 = Sample processing and/or shipment </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">14 = Evaluate study related test results</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">15 = Use IWRS/IVRS</span>
      </div> </td> 
     <td colspan="4" style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 222.25pt; "> <a name="bm_Text21"></a><a name="bm_Text22"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.50; ">
       <span style="font-family:Times New Roman;font-size:9pt;">16 = Make entries/corrections on CRFs <br />17 = Sign off CRF <br />18 = Maintain essential documents <br />19 = Perform study related assessments as per protocol <br />20 = Other (specify): &nbsp;</span>
       <span style="font-family:Times New Roman;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:9pt;">     </span>
       <span style="font-family:Times New Roman;font-size:9pt;"> <br />21 = Other (specify):</span>
       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">     </span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Name</span>
      </div> </td> 
     <td colspan="2" style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Role </span>
      </div> </td> 
     <td colspan="3" style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Key Study Task(s) &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">(choose from list below)</span>
      </div> </td> 
     <td colspan="2" style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Initials</span>
      </div> </td> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Signature</span>
      </div> </td> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Start Date </span>
       <span style="font-family:Times New Roman;font-size:8pt;font-weight:bold;">(dd/mmm/yyyy)</span>
      </div> </td> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">PI Initial</span>
      </div> </td> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">End Date </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:8pt;font-weight:bold;">(dd/mmm/yyyy)</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">(If prior to EOS)</span>
      </div> </td> 
     <td style=" border-bottom:solid 1px #000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">PI Initial</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td colspan="7" style=" border-right-color:#000000;border-left:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 354.75pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Investigator Signature:</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Comment: </span>
      </div> </td> 
     <td colspan="6" style=" border-left-color:#000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 392.05pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Date:</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:51.60pt; "> 
     <td colspan="13" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 746.80pt; "> 
      <table cellspacing="0" style="width: 746.80pt; margin-left: 0; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:64.50pt; "> 
         <td style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 174.30pt; "> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;font-weight:bold;">Task Key:</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">1 = Obtain Informed Consent</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">2 = Subject selection/recruitment </span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">3 = Confirm eligibility (review inclusion/exclusion criteria) </span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">4 = Obtain medical history (source documents) </span>
          </div> </td> 
         <td style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 173.30pt; "> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">5 = Perform physical exam</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">6 = Conduct study visit procedure as outlined in the protocol &nbsp;</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">7 = Make study related medical decisions</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">8 = Assess AEs/SAEs </span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">9 = Dispense study drug</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
          </div> </td> 
         <td style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 176.95pt; "> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">10 = Perform drug accountability &nbsp;</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">11 = Study drug storage and temperature monitoring</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">12 = Sample collection</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">13 = Sample processing and/or shipment </span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">14 = Evaluate study related test results</span>
          </div> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
           <span style="font-size:9pt;">15 = Use IWRS/IVRS</span>
          </div> </td> 
         <td style=" border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;border-top:solid 1px #000000;width: 222.25pt; "> 
          <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.50; ">
           <span style="font-size:9pt;">16 = Make entries/corrections on CRFs <br />17 = Sign off CRF <br />18 = Maintain essential documents <br />19 = Perform study related assessments as per protocol <br />20 = Other (specify): &nbsp;</span>
           <span style="font-size:9pt;">&nbsp;</span>
           <span style="font-size:9pt;">     </span>
           <span style="font-size:9pt;"> <br />21 = Other (specify):</span>
           <span style="font-size:9pt;font-weight:bold;">&nbsp;</span>
           <span style="font-size:9pt;font-weight:bold;">&nbsp;</span>
           <span style="font-size:9pt;font-weight:bold;">     </span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 113.45pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 106.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 134.70pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 43.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 126.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 42.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 38pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:11.60pt; "> 
     <td colspan="7" style=" border-right-color:#000000;border-left:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 354.75pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Investigator Signature:</span>
      </div> </td> 
     <td colspan="6" style=" border-left-color:#000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 392.05pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Date:</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:64.50pt; "> 
     <td colspan="2" style=" border-bottom-color:#000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 174.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;font-weight:bold;">Task Key:</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">1 = Obtain Informed Consent</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">2 = Subject selection/recruitment </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">3 = Confirm eligibility (review inclusion/exclusion criteria) </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">4 = Obtain medical history (source documents) </span>
      </div> </td> 
     <td colspan="2" style=" border-bottom-color:#000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 173.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">5 = Perform physical exam</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">6 = Conduct study visit procedure as outlined in the protocol &nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">7 = Make study related medical decisions</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">8 = Assess AEs/SAEs </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">9 = Dispense study drug</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="5" style=" border-bottom-color:#000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 176.95pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">10 = Perform drug accountability &nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">11 = Study drug storage and temperature monitoring</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">12 = Sample collection</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">13 = Sample processing and/or shipment </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">14 = Evaluate study related test results</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:9pt;">15 = Use IWRS/IVRS</span>
      </div> </td> 
     <td colspan="4" style=" border-bottom-color:#000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 222.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.50; ">
       <span style="font-family:Times New Roman;font-size:9pt;">16 = Make entries/corrections on CRFs <br />17 = Sign off CRF <br />18 = Maintain essential documents <br />19 = Perform study related assessments as per protocol <br />20 = Other (specify):____________________________ <br />21 = Other (specify):____________________________</span>
      </div> </td> 
    </tr> 
    <tr style=" height:28.80pt; "> 
     <td colspan="13" style=" border-bottom-color:#000000;border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;width: 746.80pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">End of Study Declaration: &nbsp;&nbsp;</span>
       <span style="font-family:Times New Roman;font-size:11pt;">I hereby confirm that the above information is accurate and complete, and that I authorized the delegation of study- related tasks to each individual as listed above.</span>
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:23.55pt; "> 
     <td colspan="5" style=" border-top-color:#000000;border-bottom:solid 1px #000000;border-right-color:#000000;border-left:solid 1px #000000;width: 353.25pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Principal Investigator Signature:</span>
      </div> </td> 
     <td colspan="8" style=" border-top-color:#000000;border-left-color:#000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 393.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1.15; ">
       <span style="font-family:Times New Roman;font-size:11pt;font-weight:bold;">Date:</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <ol class="cstlDefaultStyle cstlListParagraph" style="padding-top: 0pt; text-indent: 0pt; list-style-type: none; padding-left: 10pt; font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;"> 
   <li><span style="font-size:11pt;">●&nbsp;It is the Principal Investigators’ (PI) responsibility to supervise the conduct of the clinical investigation and to protect the rights, safety and welfare of participants in clinical trials. &nbsp;&nbsp;Per ICH GCP, the PI should maintain a list of appropriately qualified and trained persons to whom the investigator has delegated significant trial related duties.</span></li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlListParagraph" style="padding-top: 0pt; text-indent: 0pt; list-style-type: none; padding-left: 10pt; font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;"> 
   <li><span style="font-size:11pt;">●&nbsp;To fulfil the requirements stated in ICH GCP all personnel performing study related procedures must be listed on the log. &nbsp;</span></li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlListParagraph" style="padding-top: 0pt; text-indent: 0pt; list-style-type: none; padding-left: 10pt; font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;"> 
   <li><span style="font-size:11pt;">●&nbsp;All staff delegated to study related duties must be able to show evidence of appropriate education and training to confirm they are qualified to perform the delegated task.</span></li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlListParagraph" style="padding-top: 0pt; text-indent: 0pt; list-style-type: none; padding-left: 10pt; font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;"> 
   <li><span style="font-size:11pt;">●&nbsp;The log should be updated as new personal are added or removed and/or study roles change. &nbsp;Changes must be approved by the PI before they are implemented.</span></li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlListParagraph" style="padding-top: 0pt; text-indent: 0pt; list-style-type: none; padding-left: 10pt; font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;"> 
   <li><span style="font-size:11pt;">●&nbsp;This log may be completed electronically; however the signature and initial columns are to be handwritten to validate signatures/initials used for consenting, source document completion and CRF entry.</span></li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlListParagraph" style="padding-top: 0pt; text-indent: 0pt; list-style-type: none; padding-left: 10pt; font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;"> 
   <li><span style="font-size:11pt;">●&nbsp;At the End of Study (EOS) the PI must strike through unused lines and sign the PI Declaration</span></li> 
  </ol> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;line-height: 1; ">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="margin-bottom:5px;background-color:#E7EAEF;">&nbsp;</p>
  <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   &nbsp;&nbsp;
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-size:9pt;">Delegation of Responsibility Log, Version 1.0, 20160804</span>
  </div> 
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   Protocol Number: ___________
  </div> 
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-size:11pt;">Page </span>
   <span style="font-size:11pt;font-weight:bold;">_</span>
   <span style="font-size:11pt;">&nbsp;of </span>
   <span style="font-size:11pt;font-weight:bold;">_</span>
  </div> 
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>  
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