Diabetes Prevention Trial - Type 1. INSULIN INFUSION FLOW-SHEET Page 1 of 6
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1 Diabetes Prevention Trial - Type 1 Form IF INSULIN INFUSION FLOW-SHEET Page 1 of 6 Subject ID #: Subject Initials: Testing Location Code: F M L (use codes provided by DMU) Physician s signature: Name of person completing form (please print): Concentration of insulin infusion: 10 Units/500cc 25 Units/500cc Subject weight:. kg Initial infusion rate:. ml/hr Incremental increase rate: cc/hr Maximal basal rate: cc/hr Incremental decrease rate: cc/hr Minimal basal rate: cc/hr Total number of hours of infusion: hrs Number of interruptions during infusion: Day 1 Date of Infusion: / / Interim Values 04:00 06:00 Infusion rate adjusted due to BG mg/dl? (0=no 1=yes, adjusted down) IF01 - REV 09/26/97 I F DMU Use Only - Day 1 Date rcvd:
2 Subject ID #: Page 2 of 6 Day 2 Date of Infusion: / / Interim Values 04:00 06:00 Infusion rate adjusted due to BG mg/dl? (0=no 1=yes, adjusted down) IF02 - REV 09/26/97 DMU Use Only - Day 2
3 Subject ID #: Page 3 of 6 Day 3 Date of Infusion: / / Interim Values 04:00 06:00 Infusion rate adjusted due to BG mg/dl? (0=no 1=yes, adjusted down) IF03 - REV 09/26/97 DMU Use Only - Day 3
4 Subject ID #: Page 4 of 6 Day 4 Date of Infusion: / / Interim Values 04:00 06:00 Infusion rate adjusted due to BG mg/dl? (0=no 1=yes, adjusted down) IF04 - REV 09/26/97 DMU Use Only - Day 4
5 Subject ID #: Page 5 of 6 Day 5 Date of Infusion: / / Interim Values 04:00 06:00 Infusion rate adjusted due to BG mg/dl? (0=no 1=yes, adjusted down) IF05 - REV 09/26/97 DMU Use Only - Day 5
6 Subject Weight Subject ID #: Page 6 of 6 Infusion Worksheet Incremental Increase Amount Incremental Decrease Amount Concentration Basal U/kg/hr Maximum Infusion kg U/500 ml ml/hr ml/hr ml/hr ml/hr ml/hr units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml units/500 ml IF06 - REV 09/26/97 Minimum Infusion
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