SWP PHARMACEUTICALS, INC. - DATA MANAGEMENT PLANA Prospective,.docx

SWP PHARMACEUTICALS, INC. - DATA MANAGEMENT
PLAN
A Prospective, Multicenter, Randomized, Double-Blind, Phase 3
Clinical Study to Compare the Efficacy and Safety of XYZ
Versus Corticosteroid for the Treatment of Lateral Epicondylitis
(LE), Protocol Number ASUCNHI/XYZ-LE/16-17/001
Overview
21 CFR 312.50 spells out the responsibilities of the study
sponsor in the management of clinical trial data and the
verification of study data for completeness and accuracy.
Thorough review of source data is important to ensure adequate
protection of the rights, welfare, and safety of human subjects
and the quality and integrity of the clinical investigation data.
(FDA, 2013). Sponsor review of source data includes meeting
the regulatory requirements for recordkeeping and data
verification by use of the ALCOA principle. ALCOA is the
acronym for the required components of data. These include:
A = Attributable: originator of the data; who entered the data;
audit trail
L = Legible: human readable form, modifications should not
obscure original data; audit trail
C = Contemporaneous: time of data entry should be close to
when procedure performed; audit trail
O = Original: earliest record, modifications should not obscure
original data; audit trail
A = Accurate: correct and complete; valid representation of
source data, corrections documented, quality
processes/measures used; audit trail.
SWP builds it data management plans around the ALCOA
principles with the expectation that chosen study sites comply

with ALCOA and the SWP Data Management Plan.
Definitions:
· Data Element - smallest unit of information collected on a
clinical trial subject
· Data Originator – original source of the data; may be
electronic or human; tied to the data element
· eCRF – electronic Case Report Form
· Source Data - original data (electronic or written)
· EDC - Electronic Data Capture System is provided by the
sponsor, data base is created to collected subject data and
follows the eCRF format. Data will be either manually entered
into the EDC or transferred from a paper form and entered by an
individual or automatic transmission from the device into the
eCRF.
· Paper - paper forms used to collect subject data
· Electronic - data electronically transferred to the EDC such as
EKG results, blood pressure monitors
· Data Element Identifiers – data that identifies the originator
including log-in credentials, password, date, time, and subject
tied to data.
· Access - Access to study data is limited to study staff who
record the data, review the data, and enter the data. For the
sponsor, the site monitor generally referred to as a Clinical
Research Associate (CRA), statisticians, data entry and data
management staff.
· Data Review -
· Data must be reviewed by the study site monitor to verify
accuracy and completeness.
· Data reviewed by study coordinator
· Data reviewed by Data entry and data management staff
· Data entered into the EDC must be reviewed and electronically
signed off by site investigator
· Data Modifications & Corrections - to correct data on paper
forms, individual correcting data must use black ink and using
one-line cross through data, add the correct data in the comment

box or next to incorrect data, include reason for change, initial
and date the correction. Original data must not be obscured by
corrections on paper forms. EDC systems must include
functions maintain original data and corrected data, data and
time, user, reason for correction/change as required by 21 CFR
11.
· DSMB - Data Safety Monitoring Board. SWP has assigned a
DSMB for this study. All adverse events and serious adverse
events will be submitted to the DSMB for review. Events to be
submitted on a quarterly basis.
· Clinical Research Associate (CRA)/Monitor - Sponsor
representative responsible for monitoring the study site to
verify subject data and compliance with study protocol and
applicable regulations.
· Data Queries - When a monitor notes an inconsistency in data
or incorrect data, the monitor will create a query. The
individual responsible for the data must review the data query
and correct inaccuracies, etc. All queries will be reported and
resolved through the EDC system.
Data Points
The following data in Table 1 must be collected on each study
subject at the following visits:
Table 1: Schedule of events:
No
Evaluations
Screening
Day 0
Visit 1
Day 1
Visit 2 Week 2
Visit 3 Week 4
Visit 4 Week 12
Visit 5 Week 24
1
Informed Consent

X
2
Inclusion/Exclusion Criteria
X
3
Demographic Data
X
4
Medical History
X
5
Clinical Evaluation
X
X
X
X

X
X
6
Urinary Pregnancy Test
For Female Subjects
X
X
X
X
X
7
Ultrasonography
X
8
Randomization
X
9
Study Drug/Control Drug
(Administered under USG guidance)
X

10
VAS Score
X
X
X
X
X
11
PRTEE Score
X
X
X
X
X
12
ASES Score
X
X
X
X
X
13
Physiotherapy
X
X
X
X
X
14
Adverse Event
X

X
X
X
X
15
Concomitant Medication
X
X
X
X
X
Table 2 lists the individual data points that need to be collected
for each of the study events. Refer to Table 1 to identify, which
events occur at each visit.
Table 2: Individual Data Points Per Event
Event
Data
Data Point
Informed Consent
Subject ID
Subject Study ID
Date
mm/dd/yyyy
Subject signed & dated
Yes or No
Subject allowed time to review and ask questions
Yes or No
Subject signed prior to initiating study procedures

Yes or No
Subject signed & dated HIPAA
Yes or No
Site designee signed & dated
Yes or No / initials / date / time
Demographic Data
Age
Years
Gender
Male or Female
Race
Hispanic or Latino
Not Hispanic or Latino
Ethnic Group
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Dominant Arm
Right or Left
Height
Feet & Inches
Weight
Pounds
Medical History
Diagnosis of LE

Yes or No
Date of diagnosis
mm/dd/yyyy
Prior treatments for LE
list
Physical Exam
Exam completed by
MD, NP, RN or PA
Name of examiner
First & Last Name
RS
Notes / Abnormality Yes or No; If Yes explain abnormality and
any follow-up required; date of follow-up; results
CVS
PA
CNS
Ultrasound
Completed
Yes or No
Results
List
Eligible

Yes or No / Physician Name
Concomitant Medications
Reviewed with subject
Yes or No
Medication
Generic name
Route
Oral, IM, IV, Other (specify)
Dose
Dose amount
Frequency
OD, BD, TID, QID, Other (specify)
Indication
Disease or condition
Start Date
mm/dd/yyyy
End Date
mm/dd/yy or ongoing
Related to AE
Yes or No, AE# if yes
Adverse Events
Reviewed with subject
Yes or No
Event
Name & describe

Start date
mm/dd/yyyy
End Date
mm/dd/yyyy, or ongoing
Severity (determined by PI)
Mild, moderate, severe
Frequency
Single, Intermittent, Continuous
Infusion Related Toxicity
Yes or No
Relationship to IP
Unclassifiable, Unrelated, Unlikely, Possibly, Probably,
Definitely
Action
None,
Medication - started, discontinued,modified,
Hospitalization
Others (specify)
Outcome
Complete Recovery, Recovered w/ sequelae, Ongoing,
Died,
Unknown
Others (specify)
Serious
Yes or No
Reported to the IRB
Yes or No and mm/dd/yyyy

Reported to Sponsor
Reported to DSMB
Serious Adverse Event
Event
Name & describe
Start date
mm/dd/yyyy
End Date
mm/dd/yyyy, or ongoing
Treatment
Describe
Required ER visit
Yes or No; Name of ER, Name of Health Care Provider(s), Date
mm/dd/yyyy
Required hospitalization
Yes or No; Name of Hospital, Name of Health Care Provider(s),
Date mm/dd/yyyy
Related to product
Unclassifiable, Unrelated, Unlikely, Possibly, Probably,
Definitely
Reported to the IRB
Yes or No; date-mm/dd/yyyy
Reported to Sponsor

Reported to DSMB
Drug Administration
Administered by
Name
Date
mm/dd/yyyy
Drug ID #; Lot #
ID Number; Lot #
Dose
Amount
Anesthesia Used
Yes or No; if yes name of anesthesia and dose
Pregnancy Test
Gender
Male or Female
Performed
Yes or No
If Female & not preformed, reason
Menopause, hysterectomy,
Results
Positive or Negative
Physiotherapy
Conducted
Yes or No
Therapist
Name

Exercises
List exercises
Frequency per week/exercise
1x/2x/3x/4x/5x
Duration
# weeks
VAS
Assessor
Name
Score
0 - 100
PRTEE
Assessor
Name
Score at rest
0 - 10
Score with repeated arm movement
0 - 10
Score carrying a plastic bag of groceries
0 - 10
When pain was least
0 - 10
When pain was worst
0 - 10

Pain - Turn a doorknob or key
0 - 10
Pain – carry grocery bag or briefcase by handle
0 - 10
Pain - Lift a full cup of coffee or glass of milk
0 - 10
Pain – Open a jar
0 - 10
Pain - Pull up pants
0 - 10
Pain – wring our washcloth or towel
0 - 10
Pain – personal activities (dressing, washing)
0 - 10
Pain - House work (cleaning, maintenance)
0 - 10
Pain – work (job or everyday work)
0 - 10
Pain - Recreational or sport activities
0 - 10

ASES - Pain
Assessor
Name
Experience pain in elbow
Yes or No
When at it’s worse
0 - 10
At rest
0 - 10
Lifting heavy object
0 - 10
When doing repeated elbow movements
0 - 10
At night
0 - 10
ASES - Ability to do activities
Assessor
Name
Arm
Right or Left
Button shirt
0 - 3
Manage toileting
0 - 3
Comb hair

0 - 3
Tie shoes
0 - 3
Eat with utensil
0 - 3
Carry a heavy object
0 - 3
Rise from chair pushing with arm
0 - 3
Do heavy household chores
0 - 3
Turn a key
0 - 3
Throw a ball
0 - 3
Do usual work
0 - 3
Do usual sport
0 - 3
ASES - Physician Assessment: Motion
Assessor
Name
Flexion

Right score - degree
Left score - degree
Extension
Left score - degree
Flexion/Extension Arc
Left score - degree
Pronation
Left score - degree
Supination
Left score - degree
Pronation/Supination Arc
Left score - degree
ASES - Physician Assessment: Stability
Assessor
Name
Testing affected by pain
Right Arm – Yes or No
Left Arm - Yes or No
Flexion
Right Arm - score
Left Arm - score
Extension
Right Arm - score
Left Arm - score
Pronation
Right Arm - score
Left Arm - score
Supination

Right Arm - score
Left Arm - score
Grip Strength (kg)
Right Arm - score
Left Arm - score
Data Collection
All study data is to be collected and recorded at the time the
event/procedure occurs, whether electronically or on paper.
Electronic Data
The following data components will be collected electronically
and transferred directly to the electronic data capture (EDC)
system:
· Blood pressure measures
· Randomization
· Ultrasound readings
· VAS data/scores
· ASES data/scores
· PRTEE data/scores
Equipment used to record these data will be connected to the
EDC system through software provided by SWP
Pharmaceuticals. SWP Pharmaceuticals will provide physician
assessor with tablet containing assessments and connected to
the EDC for automatic transmission of assessment scores.
Paper
The remaining data points will be collected on the paper CRF
provided by SWP Pharmaceuticals. Data collected on source
documents, such as urine pregnancy will be transferred from
source to CRF. The site is responsible for maintaining a subject
binder for each subject that includes all CRFs, source
documents, notes to file, informed consent, and other essential

documents. Subject binders must be stored in a locked area with
limited access.
Data Validation
The use of a second staff member to enter data provides a
second check of data. The EDC has checks and balances
included in the program to verify data is entered correctly.
Parameters are built around the data points (such as date limits,
age boundaries, proper format of data) to ensure incorrect data
options cannot be entered into the system.
Transfer of Data
Data collected on CRFs should be transferred to the EDC on the
same day as the subject visit, but no later than two (2) business
days after date of subject visit. Data should be entered by a
study staff member different from the staff member who
collected the data. This will provide a second check for
accuracy of data.
Data Access
Only study personnel who have signed a confidentiality
agreement and require access to study data to perform their job
responsibilities are allowed access to study data. Each person
with access must have a verified e-signature on file, and have
been assigned an individual and confidential identification and
password.
IDs and passwords must not be shared with other staff. Only the
assigned individual is to use the password. Passwords must be
changed every 180 days, no password can be used more than
once. Passwords must be 8 – 16 characters and include at least
one uppercase letter, one number and one of the following
special characters & % # - _ ( ). The sponsor should review the

site policy to verify that it includes specific instructions to not
share access codes and passwords.
When a staff member is no longer employed, their ID and
password must be removed by the system administrator within
24 hours. When a staff member is terminated their ID and
password must be removed immediately.
Investigator Responsibilities
· The site investigator is responsible for ensuring that study
data is accurate and complete. This is accomplished by
assigning qualified staff to the collect study data and enter data
into the EDC.
· The investigator must review subject CRFs that have been
entered into the EDC, date and sign that they have been
reviewed and are complete.
· Investigator must ensure that data is entered into the EDC
within set time.
Ensure that sites AEs and SAEs are reported to the DSMB on a
quarterly basis by required deadline.
· The investigator is responsible for storing study records for
the time required by the FDA and/or agreed upon in the clinical
trial agreement between the site and the sponsor.
Sponsor Responsibilities
· The sponsor will provide the EDC system and provide training
to appropriate staff.
· The sponsor will provide the study site with CRFs.
· The sponsor will provide tablets with software installed to
transmit electronically captured data to the EDC.
· Sponsor will assign a clinical research associate (CRA) to
monitor the site verifying study data and site compliance with
protocol, GCPs and applicable regulations.
· The sponsor will provide the DSMB report to each study site

within 30 days of the DSMB meeting.
Data Safety and Monitoring Board (DSMB)
SWP Pharmaceuticals has assigned a DSMB for this study who
will review adverse and serious adverse events for trends and
possible safety issues. The DSMB will meet on a quarterly basis
to review safety data from all study sites. Each study site must
submit AEs and SAEs to the DSMB fifteen (15) days prior to
the scheduled meeting. The DSMB will submit quarterly review
reports to the sponsor who will submit copies of report to each
study site (within 30 days of the DSMB meeting).
Monitoring
The CRA will monitor the site on a regular basis. Monitoring
will consist of reviewing data via the EDC at a central location
and by visits at the study site. While on site the monitor will
review subject binders to verify data against source documents
and check that the data is complete and accurate. When visiting
study sites the monitor will also review study records and the
conduct of the study for compliance with GCPs, study protocol,
and applicable regulations. (Details of monitoring can be found
in the Sponsor Monitoring Plan - refer Exercise 1.2: Sample
Answer).
When a monitor identifies data that is incorrect or incomplete,
he or she will generate a data query via the EDC and assign it to
the study coordinator or the staff member who was the
originator of the data. The originator of the data is responsible
for reviewing and resolving the query within two (2) business
days of being notified that the query has been generated in the
EDC. Queries are to be resolved via the EDC.
Record Storage & Maintenance

All study documents must be stored in a safe and secure
location for a period of two (2) years post approval of the
medical product or two years post termination of the study or
records are to be stored longer by request of sponsor as covered
in the clinical trial agreement (CTA). The site will provide the
sponsor with the name and location of storage facility. At the
end of the required period the site is responsible for destroying
the records in a confidential manner. A note or copy of receipt
of destruction of records will be sent by the site to the Sponsor.
DATA MANAGEMENT PLAN OVERVIEW
A study sponsor should create a Data Management Plan for the
study protocol. This plan should be shared with each of the
study sites. The management plan is created to ensure that data
is collected and managed properly and in compliance with
current applicable regulations and guidelines. Each site can
modify the data management plan to include site specifics, such
as individuals responsible for collecting data, oversight,
equipment used, and policies for access.
The FDA provides guidance documents and regulations (21 CFR
11) related to managing data collected in clinical trials.
Guidance includes the capture, review, and retention of
electronic source data in FDA-regulated clinical investigations.
The guidance is the FDAs effort to ensure the reliability,
quality, integrity, and traceability of data from electronic source
to electronic regulatory submission. (FDA, 2013).
In Guidance for Industry Electronic Source Data in Clinical
Investigations (2013) the FDA provides the following
definitions related to data management:
· An “electronic record as any combination of text, graphics,
data, audio, pictorial, or other information represented in digital
form that is created, modified, maintained, archived, retrieved,
or distributed by a computer system.”

· “An eCRF is an example of an electronic record. The eCRF is
an auditable electronic record of information that generally is
reported to the sponsor on each trial subject, according to a
clinical investigation protocol. The eCRF enables clinical
investigation data to be systematically captured, reviewed,
managed, stored, analyzed, and reported.”
· “Source data includes all information in original records and
certified copies of original records of clinical findings,
observations, or other activities in a clinical investigation used
for reconstructing and evaluating the investigation.”
A Data Management Plan should include the following:
· Data Elements - smallest unit of observation collected on a
clinical trial subject. Examples of data elements are weight,
height, race, pain severity, etc.
· Data Originators - each data element is associated with an
originator, which is the source of that data. Originators might
include the study coordinator, the investigator, medical devices
such as EKG, consultants, etc.
· eCRFs - the electronic record where data elements are
captured.
· Source Documents - the original source of the data element,
which can be paper-based or electronic. The source data might
be manually entered into the eCRF (for example a radiology
report) or electronically transmitted by a medical device (blood
pressure monitor).
· Transfer of Source Data Elements into EDC
Paper - manually transferred into the eCRF. The person
transcribing the data from the paper source is considered the
data originator.
Electronic Transmission - automatic transmission from the
device into the eCRF.
· Access - limited access to data by appropriate study staff is
important. Access should only be granted to the investigator,
study coordinator, data entry staff (if applicable), and data
manager (if applicable). Data management must comply with

security and privacy measures covered in 21 CFR 11 and
HIPAA. The data management plan should include a list of
individuals with access to the eCRFs. Individuals with access
should have completed appropriate training. Individuals with
access should have their own identification codes and
passwords. Site policy should include specific instructions to
not share access codes and passwords and the consequences of
doing so.
· Data Element Identifiers - this is the information that
identifies the data originator. These identifiers include:date and
time of data entry, originator identification, the subject tied to
the data, any changes made and who made the change, when and
the reason for change.
· Modifications and Corrections – all data must provide a
complete audit trail that allows the reconstruction of the data
from initial entry. Only the investigator or qualified clinical
study staff should perform modifications to the data.
· Data Review
· Investigator - the investigator is responsible for the conduct of
the study and should review and electronically sign-off on
eCRFs.
· Monitor - the sponsor is responsible for verifying the data
collected in the study is accurate and complete. A clinical
research associate (CRA), representative from the sponsor must
monitor the study data on a regular basis.
· DSMB - depending on the risk involved in a study, an
independent data safety monitoring board (DSMB) may be
assigned to review study events to determine that the risk to the
subjects is not too great. This board will look for trends in
adverse and serious adverse events and provide
recommendations on study safety.
· Retention of Records - the investigator is responsible for
ensuring that study records are accurate and complete, storing,
and maintaining the study records for the required time.
References:

Food and Drug Administration (FDA). (2013) Guidance for
Industry Electronic
Source Data in Clinical Investigations
FDA. Code of Federal Regulations, Title 21 part 11: Electronic
Records; Electronic Signatures.
Code of Federal Regulations, Title 21 § 50.3: Definitions.
Code of Federal Regulations, Title 21 part 312: Investigational
New Drug
Application.
Code of Federal Regulations, Title 21 part 812: Investigational
Device Exemptions.
Code of Federal Regulations, Title 45 part 170: Health
Information Technology Standards, Implementation
Specifications, and Certification Criteria and Certification
Programs for Health Information Technology.
Food and Drug Administration, guidance for industry on
Computerized Systems Used in Clinical Investigations,
available at:
http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInfor
mation/Guidances/default.htm.
Food and Drug Administration, ICH guidance for industry E6
Good Clinical Practice: Consolidated Guidance, available at:
http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInfor
mation/Guidances/default.htm.

GOOD CLINICAL TRIALS - DATA MANAGEMENT PLAN
A Prospective, Multicenter, Randomized, Double-Blind, Phase 3
Clinical Study to Compare the Efficacy and Safety of XYZ
Versus Corticosteroid for the Treatment of Lateral Epicondylitis
(LE), Protocol Number ASUCNHI/XYZ-LE/16-17/001
Overview
Data Management Staff Roles and Responsibilities
Data Management Staff Roles and Responsibilities
Staff Role
Responsibilities
·
·
·
·
·
·
Site Policies
Data Access

Data Entry & Cleaning
Monitor Visits
Database Closure Checks
Data Archiving Record Storage and Retention
Adverse and Serious Adverse Events Management &
Reconciliation

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