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

Mots-clés

Versions (1)
  1. 07/03/2016 07/03/2016 -
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7 mars 2016

DOI

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Licence

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

Anglais

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

1 Formulaires  
Patient contact data
Description

Patient contact data

Patient given name
Description

Name

Type de données

text

Alias
UMLS CUI [1]
C1299487
Patient surname
Description

Surname

Type de données

text

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

Date of birth

Type de données

date

Alias
UMLS CUI [1]
C0421451
Gender
Description

Gender

Type de données

integer

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

Patient address

Type de données

text

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

Phone contact

Type de données

integer

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

Cell phone number

Type de données

integer

Alias
UMLS CUI [1]
C1515258
Relative contact data
Description

Relative contact data

Given name of patient´s relative
Description

Name

Type de données

text

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

Surname

Type de données

text

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

Date of birth

Type de données

date

Alias
UMLS CUI [1]
C0421451
Gender
Description

Gender

Type de données

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

Type de données

text

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

Phone contact

Type de données

integer

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

Cell phone number

Type de données

integer

Alias
UMLS CUI [1]
C1515258
Relationship to patient
Description

Family relationship

Type de données

integer

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

Relationship

Type de données

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

Type de données

text

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

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

Type de données

text

Alias
UMLS CUI [1]
C0542341
Facility name
Description

Facility name

Type de données

text

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

Department

Type de données

text

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

Address

Type de données

text

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

Phone contact

Type de données

integer

Alias
UMLS CUI [1]
C3476398
Retour au début de la page

Similar models

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

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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])
Retour au début de la page 

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