ID

13792

Beschreibung

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

Stichworte

Versionen (1)
  1. 07.03.16 07.03.16 -
Hochgeladen am

7. März 2016

DOI

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Lizenz

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

Englisch

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

1 Formulare  
Patient contact data
Beschreibung

Patient contact data

Patient given name
Beschreibung

Name

Datentyp

text

Alias
UMLS CUI [1]
C1299487
Patient surname
Beschreibung

Surname

Datentyp

text

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

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Gender
Beschreibung

Gender

Datentyp

integer

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

Patient address

Datentyp

text

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

Phone contact

Datentyp

integer

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

Cell phone number

Datentyp

integer

Alias
UMLS CUI [1]
C1515258
Relative contact data
Beschreibung

Relative contact data

Given name of patient´s relative
Beschreibung

Name

Datentyp

text

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

Surname

Datentyp

text

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

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Gender
Beschreibung

Gender

Datentyp

integer

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

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

Datentyp

text

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

Phone contact

Datentyp

integer

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

Cell phone number

Datentyp

integer

Alias
UMLS CUI [1]
C1515258
Relationship to patient
Beschreibung

Family relationship

Datentyp

integer

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

Relationship

Datentyp

text

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

Family physician or residential care facility contact person

Name and Surname
Beschreibung

Name

Datentyp

text

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

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

Datentyp

text

Alias
UMLS CUI [1]
C0542341
Facility name
Beschreibung

Facility name

Datentyp

text

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

Department

Datentyp

text

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

Address

Datentyp

text

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

Phone contact

Datentyp

integer

Alias
UMLS CUI [1]
C3476398
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Ähnliche Modelle

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

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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