ID

16963

Beschreibung

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Social History Form. QIP Case Report Forms, UIC Quality Improvement CRF, Office of the Vice Chancellor for Research. Center for Clinical and Translational Science, UIC University of Illinois at Chicago.

Link

http://research.uic.edu/qip/toolbox/case-report-forms-crf

Stichworte

Versionen (1)
  1. 17.08.16 17.08.16 -
Hochgeladen am

17. August 2016

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Social History Form: UIC Quality Improvement CRF

Englisch

Social History Form: UIC Quality Improvement CRF

1 Formulare  
General Information
Beschreibung

General Information

Protocol Title
Beschreibung

Protocol Title

Datentyp

text

Site Number
Beschreibung

Site Number

Datentyp

integer

Subject ID
Beschreibung

Subject ID

Datentyp

integer

Visit Date
Beschreibung

Visit Date

Datentyp

date

Study Visit
Beschreibung

Study Visit

Datentyp

text

Social History Form
Beschreibung

Social History Form

1. Highest Level of Education
Beschreibung

1. Highest Level of Education

Datentyp

text

2. Occupation
Beschreibung

2. Occupation

Datentyp

text

Occupation
Beschreibung

Occupation

Datentyp

text

Occupation: If retired, please specify date
Beschreibung

Occupation

Datentyp

date

3a. Language(s) in which subject is fluent: English
Beschreibung

3a. Language

Datentyp

boolean

Language(s) in which subject is fluent: Spanish
Beschreibung

Language

Datentyp

boolean

Language(s) in which subject is fluent: Chinese
Beschreibung

Language

Datentyp

boolean

Language(s) in which subject is fluent: Tagalog
Beschreibung

Language

Datentyp

boolean

Language(s) in which subject is fluent: Korean
Beschreibung

Language

Datentyp

boolean

Language(s) in which subject is fluent: Russian
Beschreibung

Language

Datentyp

boolean

Language(s) in which subject is fluent: Polish
Beschreibung

Language

Datentyp

boolean

Language(s) in which subject is fluent: Other
Beschreibung

Language

Datentyp

boolean

If Other, please specify
Beschreibung

Language

Datentyp

text

3b. Language in which subject requests study visits to be conducted
Beschreibung

3b. Language in which subject requests study visits to be conducted

Datentyp

text

If Other, please specify
Beschreibung

Language

Datentyp

text

4. Tobacco/Nicotine History
Beschreibung

If Yes, Complete information for ALL that are applicable

Datentyp

boolean

Cigarettes
Beschreibung

Tobacco/Nicotine History

Datentyp

boolean

Cigarettes: Frequency
Beschreibung

Tobacco/Nicotine History

Datentyp

text

Cigarettes: Start Date
Beschreibung

Tobacco/Nicotine History

Datentyp

date

Cigarettes: Continuing
Beschreibung

Tobacco/Nicotine History

Datentyp

boolean

Cigarettes: Stop Date
Beschreibung

Tobacco/Nicotine History

Datentyp

date

Cigars
Beschreibung

Tobacco/Nicotine History

Datentyp

boolean

Pipe
Beschreibung

Tobacco/Nicotine History

Datentyp

boolean

Chewing tobacco/snuff
Beschreibung

Tobacco/Nicotine History

Datentyp

boolean

Other
Beschreibung

Tobacco/Nicotine History

Datentyp

boolean

If Other, please specify
Beschreibung

Tobacco/Nicotine History

Datentyp

text

Cigars/Pipe/Chewing tobacco/snuff/Other: Frequency
Beschreibung

Tobacco/Nicotine History

Datentyp

text

Cigars/Pipe/Chewing tobacco/snuff/Other: Start Date
Beschreibung

Tobacco/Nicotine History

Datentyp

date

Cigars/Pipe/Chewing tobacco/snuff/Other: Continuing
Beschreibung

Tobacco/Nicotine History

Datentyp

boolean

Cigars/Pipe/Chewing tobacco/snuff/Other: Stop Date
Beschreibung

Tobacco/Nicotine History

Datentyp

date

5. Alcohol History
Beschreibung

If Yes, Complete information for ALL that are applicable.

Datentyp

boolean

Beer
Beschreibung

Alcohol History

Datentyp

boolean

Beer: Frequency
Beschreibung

Alcohol History

Datentyp

text

Beer: Start Date
Beschreibung

Alcohol History

Datentyp

date

Beer: Continuing
Beschreibung

Alcohol History

Datentyp

boolean

Beer: Stop Date
Beschreibung

Alcohol History

Datentyp

date

Wine
Beschreibung

Alcohol History

Datentyp

boolean

Wine: Frequency
Beschreibung

Alcohol History

Datentyp

text

Wine: Start Date
Beschreibung

Alcohol History

Datentyp

date

Wine: Continuing
Beschreibung

Alcohol History

Datentyp

boolean

Wine: Stop Date
Beschreibung

Alcohol History

Datentyp

date

Hard Liquor
Beschreibung

Alcohol History

Datentyp

boolean

Hard Liquor: Frequency
Beschreibung

Alcohol History

Datentyp

text

Hard Liquor: Start Date
Beschreibung

Alcohol History

Datentyp

date

Hard Liquor: Continuing
Beschreibung

Alcohol History

Datentyp

boolean

Hard Liquor: Stop Date
Beschreibung

Alcohol History

Datentyp

date

6. Illicit Substances History
Beschreibung

If Yes, Complete information for ALL that are applicable

Datentyp

boolean

Marijuana
Beschreibung

Illicit Substances History

Datentyp

boolean

Marijuana: Frequency
Beschreibung

Illicit Substances History

Datentyp

text

Marijuana: Start Date
Beschreibung

Illicit Substances History

Datentyp

date

Marijuana: Continuing
Beschreibung

Illicit Substances History

Datentyp

boolean

Marijuana: Stop Date
Beschreibung

Illicit Substances History

Datentyp

date

Cocaine
Beschreibung

Illicit Substances History

Datentyp

boolean

Cocaine: Frequency
Beschreibung

Illicit Substances History

Datentyp

text

Cocaine: Start Date
Beschreibung

Illicit Substances History

Datentyp

date

Cocaine: Continuing
Beschreibung

Illicit Substances History

Datentyp

boolean

Cocaine: Stop Date
Beschreibung

Illicit Substances History

Datentyp

date

Other (specify)
Beschreibung

Illicit Substances History

Datentyp

boolean

Other: Frequency
Beschreibung

Illicit Substances History

Datentyp

text

Other: Start Date
Beschreibung

Illicit Substances History

Datentyp

date

Other: Continuing
Beschreibung

Illicit Substances History

Datentyp

boolean

Other: Stop Date
Beschreibung

Illicit Substances History

Datentyp

date

If Other, please specify
Beschreibung

Illicit Substances History

Datentyp

text

Completed by (initials)
Beschreibung

Completed by (initials)

Datentyp

text

Date completed
Beschreibung

Date completed

Datentyp

date

Zum Seitenanfang zurückkehren

Ähnliche Modelle

Social History Form: UIC Quality Improvement CRF

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
General Information
Protocol Title
Item
Protocol Title
text
Site Number
Item
Site Number
integer
Subject ID
Item
Subject ID
integer
Visit Date
Item
Visit Date
date
Study Visit
Item
Study Visit
text
Item Group
Social History Form
Item
1. Highest Level of Education
text
1. Highest Level of Education
Code List
1. Highest Level of Education
CL Item
Grade school graduate (1)
CL Item
Some high school (2)
CL Item
High school graduate (3)
CL Item
Some collage (4)
CL Item
College graduate (5)
CL Item
Post college graduate (6)
2. Occupation
Item
2. Occupation
text
Item
Occupation
text
2. Occupation
Code List
Occupation
CL Item
Full Time  (1)
CL Item
Part-time (2)
CL Item
Retired___ (3)
CL Item
Unknown (4)
Occupation
Item
Occupation: If retired, please specify date
date
3a. Language
Item
3a. Language(s) in which subject is fluent: English
boolean
Language
Item
Language(s) in which subject is fluent: Spanish
boolean
Language
Item
Language(s) in which subject is fluent: Chinese
boolean
Language
Item
Language(s) in which subject is fluent: Tagalog
boolean
Language
Item
Language(s) in which subject is fluent: Korean
boolean
Language
Item
Language(s) in which subject is fluent: Russian
boolean
Language
Item
Language(s) in which subject is fluent: Polish
boolean
Language
Item
Language(s) in which subject is fluent: Other
boolean
Language
Item
If Other, please specify
text
Item
3b. Language in which subject requests study visits to be conducted
text
3b. Language in which subject requests study visits to be conducted
Code List
3b. Language in which subject requests study visits to be conducted
CL Item
English (1)
CL Item
Spanish (2)
CL Item
Chinese (3)
CL Item
Tagalog (4)
CL Item
Korean (5)
CL Item
Russian (6)
CL Item
Polish (7)
CL Item
Other (8)
Language
Item
If Other, please specify
text
4. Tobacco/Nicotine History
Item
4. Tobacco/Nicotine History
boolean
Tobacco/Nicotine History
Item
Cigarettes
boolean
Tobacco/Nicotine History
Item
Cigarettes: Frequency
text
Tobacco/Nicotine History
Item
Cigarettes: Start Date
date
Tobacco/Nicotine History
Item
Cigarettes: Continuing
boolean
Tobacco/Nicotine History
Item
Cigarettes: Stop Date
date
Tobacco/Nicotine History
Item
Cigars
boolean
Tobacco/Nicotine History
Item
Pipe
boolean
Tobacco/Nicotine History
Item
Chewing tobacco/snuff
boolean
Tobacco/Nicotine History
Item
Other
boolean
Tobacco/Nicotine History
Item
If Other, please specify
text
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Frequency
text
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Start Date
date
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Continuing
boolean
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Stop Date
date
5. Alcohol History
Item
5. Alcohol History
boolean
Alcohol History
Item
Beer
boolean
Alcohol History
Item
Beer: Frequency
text
Alcohol History
Item
Beer: Start Date
date
Alcohol History
Item
Beer: Continuing
boolean
Alcohol History
Item
Beer: Stop Date
date
Alcohol History
Item
Wine
boolean
Alcohol History
Item
Wine: Frequency
text
Alcohol History
Item
Wine: Start Date
date
Alcohol History
Item
Wine: Continuing
boolean
Alcohol History
Item
Wine: Stop Date
date
Alcohol History
Item
Hard Liquor
boolean
Alcohol History
Item
Hard Liquor: Frequency
text
Alcohol History
Item
Hard Liquor: Start Date
date
Alcohol History
Item
Hard Liquor: Continuing
boolean
Alcohol History
Item
Hard Liquor: Stop Date
date
6. Illicit Substances History
Item
6. Illicit Substances History
boolean
Illicit Substances History
Item
Marijuana
boolean
Illicit Substances History
Item
Marijuana: Frequency
text
Illicit Substances History
Item
Marijuana: Start Date
date
Illicit Substances History
Item
Marijuana: Continuing
boolean
Illicit Substances History
Item
Marijuana: Stop Date
date
Illicit Substances History
Item
Cocaine
boolean
Illicit Substances History
Item
Cocaine: Frequency
text
Illicit Substances History
Item
Cocaine: Start Date
date
Illicit Substances History
Item
Cocaine: Continuing
boolean
Illicit Substances History
Item
Cocaine: Stop Date
date
Illicit Substances History
Item
Other (specify)
boolean
Illicit Substances History
Item
Other: Frequency
text
Illicit Substances History
Item
Other: Start Date
date
Illicit Substances History
Item
Other: Continuing
boolean
Illicit Substances History
Item
Other: Stop Date
date
Illicit Substances History
Item
If Other, please specify
text
Completed by (initials)
Item
Completed by (initials)
text
Date completed
Item
Date completed
date
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video