**Arm:___________ARTICLE  ID:___________YEAR:_________REVIEWER A:_________B:________**

ARM NAME:

(*Prefer use treatment name here)*

**1**.Generic name

**2**.Type

Med       Surg      Altern 

((      ( 

Med       Surg      Altern 

((      ( 

Med       Surg      Altern 

((      ( 

**3**.Availability (*in 1999*)**

OTC   Rx     Study 

(     (        (

OTC   Rx     Study 

(     (        (

OTC   Rx     Study 

(     (        (

**4**.Brand name

**5**.Route

Topical      po       Other 

(        (        (

Specify *(if other)*

Topical      po       Other 

(        (        (

Specify *(if other)*

Topical      po       Other 

(        (        (

Specify *(if other)*

**6.**Vehicle

ConstituentPercent

_________________________

_________________________

_________________________

Can’t say (

ConstituentPercent

_________________________

_________________________

_________________________

Can’t say (

ConstituentPercent

_________________________

_________________________

_________________________

Can’t say (

**7**.Dose

Can’t say (

Can’t say (

Can’t say (

**8**.Units *(e.g., mg/kg)*

**9**.Frequency *(e.g., tid)*

qd  bid  tid  qid  qhs 

(  (  (  (   (

Other_______________

qd  bid  tid  qid  qhs 

(  (  (  (   (

Other_______________

qd  bid  tid  qid  qhs 

(  (  (  (   (

Other_______________

**10**.Compliance (*if monitored*)*.*

> 80% (

50–80% (

< 50% (

Can’t say  (

> 80% (

50–80% (

< 50% (

Can’t say       (  (

> 80% (

50–80% (

< 50% (

Can’t say       ( (

**11**.Ancillary

treatment

**12**.Comments

PATIENT CHARACTERISTICS FOR 

ARM                    ( 

ENTIRE STUDY (

(*Use “Entire Study” only if no arm-specific data are available)*

*For each characteristic, enter the NUMBER of patients with that characteristic (often seen in “Table 1”)*

*Intent to treat is preferred***1. Source of data**

### Characteristics of patient as they entered the study 

### Intent to treat     (

**

*Characteristics of patients during the study*

Interim               (**

**

*Characteristics of the patients left at the end of the study*

Terminal            (**

**

Can’t say            (**

**

**2.Tanner stage (# pts)**

Tanner I

Tanner II

Tanner  III

Tanner  IV

Tanner  V

Unspecified

(

**3.Age (#pts.)**

 < 31 days 

31 d to 10 y

11 y to 14 y 

15 y to 18 y

19 y to 22 y 

23 y to 26 y

27 y to 34 y

35 y to 54 y

> 54 y

*Or, if there is no breakdown..*

Mean (yrs)

Standard Deviation (yrs)

Range (yrs)

___________ to

Can’t say

(

**4.Sex (#pts.)**

Female

Male

Can’t say

(

**5Race (#pts.)**

Asian

Black

Hispanic

White

Other________________________

Can’t say

(

**6.Skin Type(#pts)**

Dry

Oily

Normal

Can’t say

          (

**7.Diet   (#pts.)**

*Was this group constituted on the basis of diet, or did they share a similar diet?*

Diet_______________________________

__________

*No, or there are no data*

Can’t say

     (

**8. Disease duration**

Mean

SD

Units

*What was the mean and SD of the duration of disease before patients came to treatment in this study; include time of prior treatment Include units (years, months..).*

_________           ________

_________________

*If there are no data on disease duration, check this radio button.*

Can’t say

                         (

**9.Acne severity(#pts)**

Mild

Moderate

Moderately severe

Severe

Other

Other

Other

Can’t say

**

Mean

_____________________

**

SD

______________________

*Indicate the WAY that acne severity was assessed  (include brief citation, if available). Select “subjective” if only “mild,” etc, used without a formal citation*

Method of assessment

 # Lesions , type (

Subjective  (

Other  (

_____________

Citation**

**10.Insurance(#pts.)**

Fee for service

Capitation

None

Can’t say

(

*Even if patients said they had insurance, does their coverage include the drugs OF THIS STUDY*

**11.Prescription plan (#pts.)**

Yes

No

Can’t say

(

*Number of lesions per patient***12. Acne Type**

Mean

SD

Range

Non-inflammatory {

Open Comedones

Closed Comedones

Total Commedones

Other non-Inflammatory

 Total Non-Inflammatory

Inflammatory {

Papules

Pustules

Other Inflammatory

Total Inflammatory

Mixed Inflammatory/non-inflammatory

Nodulocystic {

Nodules

Cysts

Nodulocysts

Other____________________________________________

*If another way of describing acne type was used, write the method here (along with a citation, if available)*

Can’t say

(

Citation

Method of assessment

*(If a multicenter site, use the majority type of source of care)***13.Source of Care (#pts.)**

Self

Generalist  

Dermatologist

Study clinic

Can’t say

(

*If a multicenter site, use the majority type of practice setting)***14.Practice Setting (#pts.)**

Self

Private practice

College/school health clinic

Staff HMO

Study site

Hospital

Can’t say

(

*At start of study, the patients were at what––***15.Phase of Care (#pts.)**

Before first MD visit

After initial MD care

After follow-up visit

After further care

After referral

Can’t Say

(

#### COMMENTS

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