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<script>
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$(function() {
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$( "#txt_date" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<div class="header_frm_page">
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<span>
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<label class="title4">28 Cycle #</label><input type="text" name="txt_cycle" style="width: 15px; border-top: 0; border-left: 0; border-right: 0" />
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<label class="title4"> Day</label><input type="text" name="txt_styDay" style="width: 15px; border-top: 0; border-left: 0; border-right: 0" />
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</span>
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<label class="title1">ECG</label>
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</div>
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<div style="margin-top: 15px; margin-bottom: 15px">
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<label>Date: </label>
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<input type="text" name="txt_date" id="txt_date" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='DD/MMM/YYYY';" value="DD/MMM/YYYY" style="border-top:0; border-left: 0; border-right: 0; width: 100px; text-align: center" />
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</div>
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<div style="margin-top: 15px; margin-bottom: 15px; line-height: 30px">
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<div style="float: left; width: 200px; border: 0px solid #ccc">
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<label>Rate: </label>
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<input type="text" name="txt_rate" style="width: 80px; border-top: 0; border-left: 0; border-right: 0" />
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</div>
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<div style="float: right; width: 400px; border: 0px solid #fcc">
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<label style="width: 100px; border: 0px solid #1cc; float: left; padding-left: 10px">Intervals:</label>
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PR<input type="checkbox" name="chk_opt1" />
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QRS<input type="checkbox" name="chk_opt2" />
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QT<input type="checkbox" name="chk_opt3" />
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QTc<input type="checkbox" name="chk_opt4" />
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</div>
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<div style="clear: both; overflow: hidden"></div>
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</div>
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<div style="margin-top: 15px; margin-bottom: 15px">
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<label style="display: block; width: 500px; line-height: 15px">Machine Interpretation: </label>
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<textarea cols="50" rows="5"></textarea>
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</div>
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<div class="header_question" style="line-height: 30px">
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<span style="float: left; width: 400px; border: 0px solid #1cc; line-height: 15px;">
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<label>Does the Investigator agree or disagree<br/>with this interpretation?</label>
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</span>
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<span style="float: left; width: 120px; border: 0px solid #fcc">
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<input type="radio" name="rbn_opt" /><label>Agree</label>
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</span>
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<span style="float: left; width: 120px; border: 0px solid #f00">
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<input type="radio" name="rbn_opt"/><label>Disagree*</label>
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</span>
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<div style="clear: both; overflow: hidden"></div>
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</div>
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<div style="margin-top: 15px; margin-bottom: 15px">
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<label style="display: block; width: 500px; line-height: 15px; height: 25px">*If disagrees, alternative interpretation must be provided below:</label>
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<textarea cols="50" rows="5"></textarea>
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</div>
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<div style="margin-top: 15px; margin-bottom: 15px">
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<div style="float: left; width: 400px; border: 0px solid #1cc; line-height: 15px;">
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<label style="display: block">Were findings clinically significant?</label>
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<label style="display: block"><small>**Report on AE page.</small></label>
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</div>
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<div style="float: left; width: 120px; border: 0px solid #fcc">
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<input type="radio" name="rbn_opt" /><label>Yes**</label>
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</div>
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<div style="float: left; width: 120px; border: 0px solid #fcc">
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<input type="radio" name="rbn_opt" /><label>No</label>
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</div>
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<div style="clear: both; overflow: hidden"></div>
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</div>
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