**Form H~2~O~2~-2. Chemical Use Log for Clinical Field Trials Using 35%
PEROX-AID^®^**

**Under INAD \# 11-669**

**[Instructions:]{.underline}** 1. Initiate Form 2 immediately upon
receipt of hydrogen peroxide (35% PEROX-AID^®^).

2\. Each lot number of hydrogen peroxide (35% PEROX-AID^®^) may be used
for multiple treatment regimes.

3\. A signed copy of Form 2 should be sent to the Study Monitor at the
end of the Study Year.

4\. Original Form 2 should be archived at the investigating facility.

**Quantity on Hand Reporting**

**From Previous Page (L): \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Facility:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Individual:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

<table style="width:100%;">
<colgroup>
<col style="width: 11%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 14%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p><strong>35% PEROX-AID<sup>®</sup></strong></p>
<p><strong>Lot Number</strong></p></td>
<td><p><strong>Date</strong></p>
<p><strong>Received</strong></p></td>
<td><strong>Amount Received<sup>1</sup> (L)</strong></td>
<td><strong>Date Used</strong></td>
<td><p><strong>Study</strong></p>
<p><strong>Number</strong></p></td>
<td><strong>35% PEROX-AID<sup>®</sup> Used for Treatment
(L)</strong></td>
<td><p><strong>35% PEROX-AID<sup>®</sup></strong></p>
<p><strong>Shipped<sup>2</sup> (L)</strong></p></td>
<td><p><strong>35% PEROX-AID<sup>®</sup></strong></p>
<p><strong>Disposal (L)</strong></p></td>
<td><p><strong>35% PEROX-AID<sup>®</sup></strong></p>
<p><strong>On-hand (L)</strong></p></td>
<td><p><strong>Inventoried by</strong></p>
<p><strong>(initials)</strong></p></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**^1^ 1 gallon = 3.785 L; 55 gallons = 208 L**

**^2^ Unused 35% PEROX-AID^®^ that is shipped to another facility
participating in 35% PEROX-AID^®^ INAD #11-669 ([Note]{.underline}: 35%
PEROX-AID^®^ can only be shipped to another facility with prior
authorization by the AADAP Office).**

  ------------------- ------------------------- ------------ ------------------------
  **Investigator:**                             **Study      
                                                Monitor:**   

                      **Signature and Date**                 **Signature and Date**
  ------------------- ------------------------- ------------ ------------------------