I

(hh:mm)

II I I (hh:mm)

II. Unscheduled Sugar Administration: (Orally) Concentration of glucose: 20%

Actual time Administered Date by

administration (hh:mm)

administration (hh:mm)

administration (hh:mm)

III. Unscheduled Sugar Administration: (Intravenously) Concentration of glucose: 20%

Actual time Administered Date by

administration (hh:mm)

administration (hh:mm)

Clinical Investigator Signature:

Date:

Exhibit 1

To be used in conjunction with SOP: CLP-016 (Revision C)

Exhibit 1

To be used in conjunction with SOP: CLP-016 (Revision C)

Sugar Administration Form

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