ID

16967

Description

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Randomization 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

Keywords

  1. 8/17/16 8/17/16 -
Uploaded on

August 17, 2016

DOI

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License

Creative Commons BY-NC 3.0

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Randomization Form: UIC Quality Improvement CRF

Randomization Form: UIC Quality Improvement CRF

Randomization Form
Description

Randomization Form

Protocol Title
Description

Protocol Title

Data type

text

Site Number
Description

Site Number

Data type

integer

Subject ID
Description

Subject ID

Data type

integer

Visit Date
Description

Visit Date

Data type

date

1. Did the subject meet the eligibility requirements for this study? (see description)
Description

(If no leave the rest of the form blank)

Data type

boolean

a. Date randomized (See description)
Description

If yes, please chose either a) or b)

Data type

date

b. If eligible and not randomized, indicate reason
Description

b. If eligible and not randomized, indicate reason

Data type

text

If Other, please specify
Description

If Other, please specify

Data type

text

2. Randomized to study group or treatment
Description

2. Randomized to study group or treatment

Data type

text

Completed by (initials)
Description

Completed by (initials)

Data type

text

Date completed
Description

Date completed

Data type

date

Similar models

Randomization Form: UIC Quality Improvement CRF

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Randomization Form
Protocol Title
Item
Protocol Title
text
Site Number
Item
Site Number
integer
Subject ID
Item
Subject ID
integer
Visit Date
Item
date
1. Did the subject meet the eligibility requirements for this study?
Item
1. Did the subject meet the eligibility requirements for this study? (see description)
boolean
a. Date randomized (See description)
Item
a. Date randomized (See description)
date
Item
b. If eligible and not randomized, indicate reason
text
Code List
b. If eligible and not randomized, indicate reason
CL Item
Failed to return (1)
CL Item
Declined participation (2)
CL Item
Other (specify) (3)
If Other, please specify
Item
If Other, please specify
text
2. Randomized to study group or treatment
Item
2. Randomized to study group or treatment
text
Completed by (initials)
Item
Completed by (initials)
text
Date completed
Item
Date completed
date

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