ID

16531

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Demographics. Case Report Form (CRF)/Source Document templates were created for University of Wisconsin-Madison researchers. These templates are consistent with the FDA's CDASH (Clinical Data Acquisition Standards Harmonization) standards. The CDASH standards identify those elements that should be captured on a Case Report Form (CRF). The forms serve only as templates, and must be edited to meet the study data collection needs as described in the protocol.

Link

https://ictr.wisc.edu/CaseReptTempt

Keywords

Versions (2)
  1. 7/22/16 7/22/16 -
  2. 11/17/16 11/17/16 -
Uploaded on

July 22, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Demographics: CRF Wisconsin Madison

English

Demographics: CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Protocol Short Title
Description

Protocol Short Title

Data type

text

Subject Initials
Description

Subject Initials

Data type

text

Subject ID
Description

Subject ID

Data type

integer

Date
Description

Date

Data type

date

Demographics
Description

Demographics

Subject UWHC Medical Record Number
Description

Subject UWHC Medical Record Number

Data type

integer

First Name
Description

First Name

Data type

text

Middle Name (or initial)
Description

Middle Name (or initial)

Data type

text

Last Name
Description

Last Name

Data type

text

Birthdate
Description

Birthdate

Data type

date

Gender
Description

Gender

Data type

text

Ethnicity
Description

Ethnicity

Data type

text

American Indian or Alaska Native
Description

Race

Data type

boolean

Asian
Description

Race

Data type

boolean

Black or African American
Description

Race

Data type

boolean

Native Hawaiian or Other Pacific Islander
Description

Race

Data type

boolean

White or Caucasian
Description

Race

Data type

boolean

Unknown or not Reported
Description

Race

Data type

boolean

Other Medical Record Number(s)
Description

Other Medical Record Number(s)

Medical Record Number
Description

Medical Record Number

Data type

integer

Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
Description

Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)

Data type

text

Contact Information
Description

Contact Information

Address
Description

Address

Data type

text

Unit number
Description

Unit number

Data type

integer

City
Description

City

Data type

text

State
Description

State

Data type

text

Zip
Description

Zip

Data type

integer

Phone number
Description

Phone number

Data type

integer

What kind of phone number is it?
Description

Phone number

Data type

text

Alternate Phone Number
Description

Alternate Phone Number

Data type

integer

What kind of Phone number is it?
Description

Alternate Phone Number

Data type

text

Email address
Description

Email address

Data type

text

Preferred method of contact
Description

Preferred method of contact

Data type

text

Emergency contact
Description

Emergency contact

Name
Description

Name

Data type

text

Address
Description

Address

Data type

text

Unit number
Description

Unit number

Data type

integer

City
Description

City

Data type

text

State
Description

State

Data type

text

Zip
Description

Zip

Data type

integer

Phone Number
Description

Phone Number

Data type

integer

What kind of phone number is it?
Description

Phone number

Data type

text

Alternate Phone Number
Description

Alternate Phone Number

Data type

integer

What kind of phone number is it?
Description

Alternate Phone Number

Data type

text

Email address
Description

Email address

Data type

text

Form completed By
Description

Form completed By

Data type

text

Date
Description

Date

Data type

date

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Similar models

Demographics: CRF Wisconsin Madison

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
PI Name
Item
PI Name
text
Protocol or IRB Number
Item
Protocol or IRB Number
integer
Protocol Short Title
Item
Protocol Short Title
text
Subject Initials
Item
Subject Initials
text
Subject ID
Item
Subject ID
integer
Date
Item
Date
date
Item Group
Demographics
Subject UWHC Medical Record Number
Item
Subject UWHC Medical Record Number
integer
First Name
Item
First Name
text
Middle Name (or initial)
Item
Middle Name (or initial)
text
Last Name
Item
Last Name
text
Birthdate
Item
Birthdate
date
Item
Gender
text
Gender
Code List
Gender
CL Item
Male (1)
CL Item
Female (2)
CL Item
Unknown or not Reported (3)
Item
Ethnicity
text
Ethnicity
Code List
Ethnicity
CL Item
Hispanic (1)
CL Item
Non-Hispanic (2)
CL Item
Unknown or not Reported (3)
Race
Item
American Indian or Alaska Native
boolean
Race
Item
Asian
boolean
Race
Item
Black or African American
boolean
Race
Item
Native Hawaiian or Other Pacific Islander
boolean
Race
Item
White or Caucasian
boolean
Race
Item
Unknown or not Reported
boolean
Item Group
Other Medical Record Number(s)
Medical Record Number
Item
integer
Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
Item
Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
text
Item Group
Contact Information
Address
Item
Address
text
Unit number
Item
Unit number
integer
City
Item
City
text
State
Item
State
text
Zip
Item
Zip
integer
Phone number
Item
Phone number
integer
Item
What kind of phone number is it?
text
Phone number
Code List
What kind of phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Alternate Phone Number
Item
Alternate Phone Number
integer
Item
What kind of Phone number is it?
text
Alternate Phone Number
Code List
What kind of Phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Email address
Item
Email address
text
Preferred method of contact
Item
Preferred method of contact
text
Item Group
Emergency contact
Name
Item
Name
text
Address
Item
Address
text
Unit number
Item
integer
City
Item
City
text
State
Item
State
text
Zip
Item
Zip
integer
Phone Number
Item
Phone Number
integer
Item
What kind of phone number is it?
text
Phone number
Code List
What kind of phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Alternate Phone Number
Item
Alternate Phone Number
integer
Item
What kind of phone number is it?
text
Alternate Phone Number
Code List
What kind of phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Email address
Item
Email address
text
Form completed By
Item
Form completed By
text
Date
Item
Date
date
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