ID

13259

Beschrijving

Prospective,multicentric,double blind and placebo-controlled Phase III clinical trial to determine efficacy and tolerability of subcutaneous hyposensitization with CLUSTOID in patients with allergic rhinoconjunctivits caused by grass or rye pollen. EudraCT-Nr. 2008-000513-29 Study-code:CLU-2008-001 Sponsor: ROXALL Medizin GmbH Carl-Petersen-Straße 4 20535 Hamburg Phone:040-8972520 Fax:040-89725223 Project coordinator: Dr.Jenny Uhlig ROXALL Medizin GmbH Head of clinical investigation: Prof.Dr.med.Ludger Klimek An den Quellen 10 65183 Wiesbaden Phone:0611-8904381 Fax:0611-3082360 Monitoring,data management and statistical evaluation: IMSIE- Institut for medical statistics,computer sciences and epidemiology University hospital Cologne Lindenburger Allee 42 50931 Cologne Phone:0221-4783456 Fax:0221-4783465

Trefwoorden

Versies (1)
  1. 27-01-16 27-01-16 -
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27 januari 2016

DOI

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Licentie

Creative Commons BY-NC 3.0
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Efficacy and tolerability of subcutaneous hyposensitization with CLUSTOID in Patients with allergic rhinoconjunctivitis AE report form

Engels

Adverse Event report form

1 Formulieren  
Adverse Events
Beschrijving

Adverse Events

Please give Patient ID composed of Study site Nr and Patient Nr
Beschrijving

Patient Identification

Datatype

integer

Alias
UMLS CUI [1]
C1269815
Did any Adverse Events occur?
Beschrijving

Adverse Events

Datatype

boolean

Alias
UMLS CUI [1]
C0877248
Please describe the AE
Beschrijving

In case of SAE please fill in the SAE-form at the end of this CRF asap (24h) and send via FAX to Roxall Medical GmbH (040/89725223)

Datatype

text

Alias
UMLS CUI [1]
C0877248
Adverse Event Start Date
Beschrijving

Adverse Event Start Date

Datatype

date

Alias
UMLS CUI [1]
C2697888
Adverse Event End Date
Beschrijving

Adverse Event End Date

Datatype

date

Alias
UMLS CUI [1]
C2697886
How often did the event occur?
Beschrijving

Adverse event occurrence

Datatype

text

Alias
UMLS CUI [1]
C2697887
Please give your opinion to the severity of the AE
Beschrijving

Adverse event severity

Datatype

text

Alias
UMLS CUI [1]
C1710066
Adverse Event Outcome
Beschrijving

Adverse Event Outcome

Datatype

text

Alias
UMLS CUI [1]
C1705586
What actions have been taken regarding the trial substance?
Beschrijving

Adverse Event actions taken

Datatype

text

Alias
UMLS CUI [1]
C2826626
What other actions have been taken in response to the AE?
Beschrijving

Adverse event actions taken

Datatype

text

Alias
UMLS CUI [1]
C2826719
Is the AE related to the trial substance?
Beschrijving

Adverse event context to trial substance

Datatype

text

Alias
UMLS CUI [1,1]
C2983596
UMLS CUI [1,2]
C0041755
Date of completion of this form
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Signature
Beschrijving

Signature

Datatype

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Adverse Event report form

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Adverse Events
Patient Identification
Item
Please give Patient ID composed of Study site Nr and Patient Nr
integer
C1269815 (UMLS CUI [1])
Adverse Events
Item
Did any Adverse Events occur?
boolean
C0877248 (UMLS CUI [1])
Adverse Event
Item
Please describe the AE
text
C0877248 (UMLS CUI [1])
Adverse Event Start Date
Item
Adverse Event Start Date
date
C2697888 (UMLS CUI [1])
Adverse Event End Date
Item
Adverse Event End Date
date
C2697886 (UMLS CUI [1])
Item
How often did the event occur?
text
C2697887 (UMLS CUI [1])
Adverse event occurrence
Code List
How often did the event occur?
CL Item
once (1)
CL Item
regularly (2)
CL Item
continuing (3)
Item
Please give your opinion to the severity of the AE
text
C1710066 (UMLS CUI [1])
Adverse event severity
Code List
Please give your opinion to the severity of the AE
CL Item
minor (1)
CL Item
moderate (2)
CL Item
severe (3)
Item
Adverse Event Outcome
text
C1705586 (UMLS CUI [1])
Adverse Event Outcome
Code List
Adverse Event Outcome
CL Item
Recovered (1)
CL Item
Subsiding (2)
CL Item
Continuing (3)
CL Item
resolved with sequelae (4)
CL Item
increased symptoms (5)
CL Item
fatal (6)
CL Item
unknown (7)
Item
What actions have been taken regarding the trial substance?
text
C2826626 (UMLS CUI [1])
Adverse Event actions taken
Code List
What actions have been taken regarding the trial substance?
CL Item
not applicable (1)
CL Item
no adjustment in dose (2)
CL Item
adjustment of dose (3)
CL Item
suspension of treatment (4)
CL Item
discontinuation of treatment (5)
CL Item
other (6)
Item
What other actions have been taken in response to the AE?
text
C2826719 (UMLS CUI [1])
Adverse event actions taken
Code List
What other actions have been taken in response to the AE?
CL Item
none (1)
CL Item
change of concomitant medication (2)
CL Item
hospitalization/prolonged stay in hospital (3)
CL Item
further therapeutic and diagnostic measures (4)
Item
Is the AE related to the trial substance?
text
C2983596 (UMLS CUI [1,1])
C0041755 (UMLS CUI [1,2])
Adverse event context to trial substance
Code List
Is the AE related to the trial substance?
CL Item
undecided/incomplete (1)
CL Item
inconclusive (2)
CL Item
without context to trial substance (3)
CL Item
unlikely (4)
CL Item
possible (5)
CL Item
probable (6)
CL Item
confirmed (7)
Date
Item
Date of completion of this form
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
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