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ID

13792

Description

Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis. A randomized controlled clinical trial. Short title: "CABACS" DRKS Number:DRKS00000521 IRSCTN Number:ISRCTN13486906 Phase:Therapeutic confirmatory(Phase III) Head of clinical trial: Prof. Dr. med. Christian Weimar University Duisburg-Essen Phone: 0201/723-6503 Fax: 0201/723-6948 e-mail: christian.weimar@uk-essen.de University Hospital Essen Hospital for Neurology Hufelandstr. 55 45122 Essen Trial coordinator: Dr. med. Stephan Knipp Phone: 0201/723-4915 Fax: 0201/723-5451 e-mail: stephan.knipp@uk-essen.de University Duisburg-Essen University Hospital Essen Hospital for thoracic- and cardiovascular surgery Hufelandstr. 55 45122 Essen Data Management: Anja Marr Phone: 0201/92239-257 Fax: 0201/92239-333 o. 0201/723-5933 e-mail: anja.marr@uk-essen.de University Hospital Essen Center for clinical trials Essen c/o IMIBE Hufelandstr. 55 45122 Essen Monitoring: Dipl.-Biol. Konstantinos Bilbilis Phone: 0201/92239-252 Fax: 0201/92239-310 e-mail: konstantinos.bilbilis@uk-essen.de University Hospital Essen Center for clinical trials Essen c/o IMIBE Hufelandstr. 55 45122 Essen

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Versions (1)
  1. 3/7/16 3/7/16 -
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March 7, 2016

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Creative Commons BY-NC 3.0
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    Contact data for annual phone contact Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis DRKS00000521

    English

    CABACS Case Report Form [Contact data for annual phone contact]

    1 forms  
    Patient contact data
    Description

    Patient contact data

    Patient given name
    Description

    Name

    Data type

    text

    Alias
    UMLS CUI [1]
    C1299487
    Patient surname
    Description

    Surname

    Data type

    text

    Alias
    UMLS CUI [1]
    C0421448
    Patient date of birth
    Description

    Date of birth

    Data type

    date

    Alias
    UMLS CUI [1]
    C0421451
    Gender
    Description

    Gender

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0079399
    Street name, house or appartement number, zip code and city of residence
    Description

    Patient address

    Data type

    text

    Alias
    UMLS CUI [1]
    C0421449
    Please enter a phone number for the annual interview
    Description

    Phone contact

    Data type

    integer

    Alias
    UMLS CUI [1]
    C3476398
    Please enter a cell phone number if applicable
    Description

    Cell phone number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1515258
    Relative contact data
    Description

    Relative contact data

    Given name of patient´s relative
    Description

    Name

    Data type

    text

    Alias
    UMLS CUI [1]
    C0027365
    Last name of patient´s relative
    Description

    Surname

    Data type

    text

    Alias
    UMLS CUI [1]
    C1301584
    Date of birth of patient´s relative
    Description

    Date of birth

    Data type

    date

    Alias
    UMLS CUI [1]
    C0421451
    Gender
    Description

    Gender

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0079399
    Home Address of patient´s relative
    Description

    Street name, house or appartement number, zip code and city of residence

    Data type

    text

    Alias
    UMLS CUI [1]
    C1442065
    Please enter a phone number to contact the patient´s relative
    Description

    Phone contact

    Data type

    integer

    Alias
    UMLS CUI [1]
    C3476398
    Please enter a cell phone number, if applicable
    Description

    Cell phone number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1515258
    Relationship to patient
    Description

    Family relationship

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0015608
    Please specify other relationship to patient
    Description

    Relationship

    Data type

    text

    Alias
    UMLS CUI [1]
    C0439849
    Family physician or residential care facility contact person
    Description

    Family physician or residential care facility contact person

    Name and Surname
    Description

    Name

    Data type

    text

    Alias
    UMLS CUI [1]
    C0027365
    Function of contact person
    Description

    i.e: family physician, contact person of residential care facility

    Data type

    text

    Alias
    UMLS CUI [1]
    C0542341
    Facility name
    Description

    Facility name

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0018704
    UMLS CUI [1,2]
    C0027365
    Department
    Description

    Department

    Data type

    text

    Alias
    UMLS CUI [1]
    C1704729
    Address:street name, house number,zip code and city of residence.
    Description

    Address

    Data type

    text

    Alias
    UMLS CUI [1]
    C1442065
    Please enter a phone number for contact
    Description

    Phone contact

    Data type

    integer

    Alias
    UMLS CUI [1]
    C3476398
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    Similar models

    CABACS Case Report Form [Contact data for annual phone contact]

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Patient contact data
    Name
    Item
    Patient given name
    text
    C1299487 (UMLS CUI [1])
    Surname
    Item
    Patient surname
    text
    C0421448 (UMLS CUI [1])
    Date of birth
    Item
    Patient date of birth
    date
    C0421451 (UMLS CUI [1])
    Item
    Gender
    integer
    C0079399 (UMLS CUI [1])
    Gender
    Code List
    Gender
    CL Item
    male (1)
    CL Item
    female (2)
    Patient address
    Item
    Street name, house or appartement number, zip code and city of residence
    text
    C0421449 (UMLS CUI [1])
    Phone contact
    Item
    Please enter a phone number for the annual interview
    integer
    C3476398 (UMLS CUI [1])
    Cell phone number
    Item
    Please enter a cell phone number if applicable
    integer
    C1515258 (UMLS CUI [1])
    Item Group
    Relative contact data
    Name
    Item
    Given name of patient´s relative
    text
    C0027365 (UMLS CUI [1])
    Surname
    Item
    Last name of patient´s relative
    text
    C1301584 (UMLS CUI [1])
    Date of birth
    Item
    Date of birth of patient´s relative
    date
    C0421451 (UMLS CUI [1])
    Item
    Gender
    integer
    C0079399 (UMLS CUI [1])
    Gender
    Code List
    Gender
    CL Item
    male (1)
    CL Item
    female (2)
    Address
    Item
    Home Address of patient´s relative
    text
    C1442065 (UMLS CUI [1])
    Phone contact
    Item
    Please enter a phone number to contact the patient´s relative
    integer
    C3476398 (UMLS CUI [1])
    Cell phone number
    Item
    Please enter a cell phone number, if applicable
    integer
    C1515258 (UMLS CUI [1])
    Item
    Relationship to patient
    integer
    C0015608 (UMLS CUI [1])
    Family relationship
    Code List
    Relationship to patient
    CL Item
    spouse/cohabitee (1)
    CL Item
    child (2)
    CL Item
    father or mother (3)
    CL Item
    friend (4)
    CL Item
    other (specify) (5)
    Relationship
    Item
    Please specify other relationship to patient
    text
    C0439849 (UMLS CUI [1])
    Item Group
    Family physician or residential care facility contact person
    Name
    Item
    Name and Surname
    text
    C0027365 (UMLS CUI [1])
    Function
    Item
    Function of contact person
    text
    C0542341 (UMLS CUI [1])
    Facility name
    Item
    Facility name
    text
    C0018704 (UMLS CUI [1,1])
    C0027365 (UMLS CUI [1,2])
    Department
    Item
    Department
    text
    C1704729 (UMLS CUI [1])
    Address
    Item
    Address:street name, house number,zip code and city of residence.
    text
    C1442065 (UMLS CUI [1])
    Phone contact
    Item
    Please enter a phone number for contact
    integer
    C3476398 (UMLS CUI [1])
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