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ID

13792

Beschrijving

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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Versies (1)
  1. 07-03-16 07-03-16 -
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7 maart 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

    Engels

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

    1 Formulieren  
    Patient contact data
    Beschrijving

    Patient contact data

    Patient given name
    Beschrijving

    Name

    Datatype

    text

    Alias
    UMLS CUI [1]
    C1299487 (Patient name)
    SNOMED
    371484003
    Patient surname
    Beschrijving

    Surname

    Datatype

    text

    Alias
    UMLS CUI [1]
    C0421448 (Patient surname)
    SNOMED
    184096005
    Patient date of birth
    Beschrijving

    Date of birth

    Datatype

    date

    Alias
    UMLS CUI [1]
    C0421451 (Patient date of birth)
    SNOMED
    184099003
    LOINC
    LP57552-9
    Gender
    Beschrijving

    Gender

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C0079399 (Gender)
    SNOMED
    263495000
    LOINC
    LP61312-2
    Street name, house or appartement number, zip code and city of residence
    Beschrijving

    Patient address

    Datatype

    text

    Alias
    UMLS CUI [1]
    C0421449 (Patient address)
    SNOMED
    184097001
    Please enter a phone number for the annual interview
    Beschrijving

    Phone contact

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C3476398 (Primary contact phone number)
    LOINC
    MTHU061006
    Please enter a cell phone number if applicable
    Beschrijving

    Cell phone number

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C1515258 (Telephone Number)
    SNOMED
    734005006
    LOINC
    LP6871-0
    Relative contact data
    Beschrijving

    Relative contact data

    Given name of patient´s relative
    Beschrijving

    Name

    Datatype

    text

    Alias
    UMLS CUI [1]
    C0027365 (Name)
    SNOMED
    703503000
    LOINC
    LP72974-6
    Last name of patient´s relative
    Beschrijving

    Surname

    Datatype

    text

    Alias
    UMLS CUI [1]
    C1301584 (Last Name)
    SNOMED
    397678008
    Date of birth of patient´s relative
    Beschrijving

    Date of birth

    Datatype

    date

    Alias
    UMLS CUI [1]
    C0421451 (Patient date of birth)
    SNOMED
    184099003
    LOINC
    LP57552-9
    Gender
    Beschrijving

    Gender

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C0079399 (Gender)
    SNOMED
    263495000
    LOINC
    LP61312-2
    Home Address of patient´s relative
    Beschrijving

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

    Datatype

    text

    Alias
    UMLS CUI [1]
    C1442065 (Address)
    SNOMED
    397635003
    LOINC
    LP96251-1
    Please enter a phone number to contact the patient´s relative
    Beschrijving

    Phone contact

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C3476398 (Primary contact phone number)
    LOINC
    MTHU061006
    Please enter a cell phone number, if applicable
    Beschrijving

    Cell phone number

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C1515258 (Telephone Number)
    SNOMED
    734005006
    LOINC
    LP6871-0
    Relationship to patient
    Beschrijving

    Family relationship

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C0015608 (Family Relationship)
    LOINC
    LA16499-8
    Please specify other relationship to patient
    Beschrijving

    Relationship

    Datatype

    text

    Alias
    UMLS CUI [1]
    C0439849 (Relationships)
    SNOMED
    263498003
    LOINC
    LP146886-9
    Family physician or residential care facility contact person
    Beschrijving

    Family physician or residential care facility contact person

    Name and Surname
    Beschrijving

    Name

    Datatype

    text

    Alias
    UMLS CUI [1]
    C0027365 (Name)
    SNOMED
    703503000
    LOINC
    LP72974-6
    Function of contact person
    Beschrijving

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

    Datatype

    text

    Alias
    UMLS CUI [1]
    C0542341 (Function (attribute))
    SNOMED
    277064003
    LOINC
    LP6812-4
    Facility name
    Beschrijving

    Facility name

    Datatype

    text

    Alias
    UMLS CUI [1,1]
    C0018704 (Health care facility)
    SNOMED
    257622000
    LOINC
    LA30302-6
    UMLS CUI [1,2]
    C0027365 (Name)
    SNOMED
    703503000
    LOINC
    LP72974-6
    Department
    Beschrijving

    Department

    Datatype

    text

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

    Address

    Datatype

    text

    Alias
    UMLS CUI [1]
    C1442065 (Address)
    SNOMED
    397635003
    LOINC
    LP96251-1
    Please enter a phone number for contact
    Beschrijving

    Phone contact

    Datatype

    integer

    Alias
    UMLS CUI [1]
    C3476398 (Primary contact phone number)
    LOINC
    MTHU061006
    Terug naar het begin van de pagina

    Similar models

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

    1 Formulieren
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    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])
    Terug naar het begin van de pagina 

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