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ID

18726

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 -
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November 17, 2016

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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

    Alias
    UMLS CUI [1]
    C0027365
    Protocol or IRB Number
    Description

    Protocol or IRB Number

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0008971
    UMLS CUI [1,2]
    C0600091
    Protocol Short Title
    Description

    Protocol Short Title

    Data type

    text

    Alias
    UMLS CUI [1]
    C2986303
    Subject Initials
    Description

    Subject Initials

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0681850
    UMLS CUI [1,2]
    C1555582
    Subject ID
    Description

    Subject ID

    Data type

    integer

    Alias
    UMLS CUI [1]
    C2348585
    Date
    Description

    Date

    Data type

    date

    Alias
    UMLS CUI [1]
    C0011008
    Demographics
    Description

    Demographics

    Subject UWHC Medical Record Number
    Description

    Subject UWHC Medical Record Number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1301894
    First Name
    Description

    First Name

    Data type

    text

    Alias
    UMLS CUI [1]
    C1443235
    Middle Name (or initial)
    Description

    Middle Name (or initial)

    Data type

    text

    Alias
    UMLS CUI [1]
    C2598119
    Last Name
    Description

    Last Name

    Data type

    text

    Alias
    UMLS CUI [1]
    C1301584
    Birthdate
    Description

    Birthdate

    Data type

    date

    Alias
    UMLS CUI [1]
    C0421451
    Gender
    Description

    Gender

    Data type

    text

    Alias
    UMLS CUI [1]
    C0079399
    Ethnicity
    Description

    Ethnicity

    Data type

    text

    Alias
    UMLS CUI [1]
    C0015031
    American Indian or Alaska Native
    Description

    Race

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0002460
    UMLS CUI [1,2]
    C0682125
    Asian
    Description

    Race

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0078988
    Black or African American
    Description

    Race

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0085756
    Native Hawaiian or Other Pacific Islander
    Description

    Race

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C3845561
    White or Caucasian
    Description

    Race

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0043157
    Unknown or not Reported
    Description

    Race

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0439673
    Other Medical Record Number(s)
    Description

    Other Medical Record Number(s)

    Medical Record Number
    Description

    Medical Record Number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1301894
    Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
    Description

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

    Data type

    text

    Alias
    UMLS CUI [1]
    C0019994
    Contact Information
    Description

    Contact Information

    Address
    Description

    Address

    Data type

    text

    Alias
    UMLS CUI [1]
    C0421449
    Unit number
    Description

    Unit number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0439148
    City
    Description

    City

    Data type

    text

    Alias
    UMLS CUI [1]
    C0008848
    State
    Description

    State

    Data type

    text

    Alias
    UMLS CUI [1]
    C1442792
    Zip
    Description

    Zip

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1521842
    Phone number
    Description

    Phone number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1515258
    What kind of phone number is it?
    Description

    Phone number

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1515258
    UMLS CUI [1,2]
    C0332307
    Alternate Phone Number
    Description

    Alternate Phone Number

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C1515258
    UMLS CUI [1,2]
    C1523987
    What kind of Phone number is it?
    Description

    Alternate Phone Number

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1515258
    UMLS CUI [1,2]
    C0332307
    Email address
    Description

    Email address

    Data type

    text

    Alias
    UMLS CUI [1]
    C1705961
    Preferred method of contact
    Description

    Preferred method of contact

    Data type

    text

    Alias
    UMLS CUI [1]
    C1997600
    Emergency contact
    Description

    Emergency contact

    Name
    Description

    Name

    Data type

    text

    Alias
    UMLS CUI [1]
    C0027365
    Address
    Description

    Address

    Data type

    text

    Alias
    UMLS CUI [1]
    C0421449
    Unit number
    Description

    Unit number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0439148
    City
    Description

    City

    Data type

    text

    Alias
    UMLS CUI [1]
    C0008848
    State
    Description

    State

    Data type

    text

    Alias
    UMLS CUI [1]
    C1442792
    Zip
    Description

    Zip

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1521842
    Phone Number
    Description

    Phone Number

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1515258
    What kind of phone number is it?
    Description

    Phone number

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1515258
    UMLS CUI [1,2]
    C0332307
    Alternate Phone Number
    Description

    Alternate Phone Number

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C1515258
    UMLS CUI [1,2]
    C1523987
    What kind of phone number is it?
    Description

    Alternate Phone Number

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1515258
    UMLS CUI [1,2]
    C0332307
    Email address
    Description

    Email address

    Data type

    text

    Alias
    UMLS CUI [1]
    C1705961
    Form completed By
    Description

    Form completed By

    Data type

    text

    Date
    Description

    Date

    Data type

    date

    Alias
    UMLS CUI [1]
    C0011008
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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
    C0027365 (UMLS CUI [1])
    Protocol or IRB Number
    Item
    Protocol or IRB Number
    integer
    C0008971 (UMLS CUI [1,1])
    C0600091 (UMLS CUI [1,2])
    Protocol Short Title
    Item
    Protocol Short Title
    text
    C2986303 (UMLS CUI [1])
    Subject Initials
    Item
    Subject Initials
    text
    C0681850 (UMLS CUI [1,1])
    C1555582 (UMLS CUI [1,2])
    Subject ID
    Item
    Subject ID
    integer
    C2348585 (UMLS CUI [1])
    Date
    Item
    Date
    date
    C0011008 (UMLS CUI [1])
    Item Group
    Demographics
    Subject UWHC Medical Record Number
    Item
    Subject UWHC Medical Record Number
    integer
    C1301894 (UMLS CUI [1])
    First Name
    Item
    First Name
    text
    C1443235 (UMLS CUI [1])
    Middle Name (or initial)
    Item
    Middle Name (or initial)
    text
    C2598119 (UMLS CUI [1])
    Last Name
    Item
    Last Name
    text
    C1301584 (UMLS CUI [1])
    Birthdate
    Item
    Birthdate
    date
    C0421451 (UMLS CUI [1])
    Item
    Gender
    text
    C0079399 (UMLS CUI [1])
    Gender
    Code List
    Gender
    CL Item
    Male (1)
    CL Item
    Female (2)
    CL Item
    Unknown or not Reported (3)
    Item
    Ethnicity
    text
    C0015031 (UMLS CUI [1])
    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
    C0002460 (UMLS CUI [1,1])
    C0682125 (UMLS CUI [1,2])
    Race
    Item
    Asian
    boolean
    C0078988 (UMLS CUI [1])
    Race
    Item
    Black or African American
    boolean
    C0085756 (UMLS CUI [1])
    Race
    Item
    Native Hawaiian or Other Pacific Islander
    boolean
    C3845561 (UMLS CUI [1])
    Race
    Item
    White or Caucasian
    boolean
    C0043157 (UMLS CUI [1])
    Race
    Item
    Unknown or not Reported
    boolean
    C0439673 (UMLS CUI [1])
    Item Group
    Other Medical Record Number(s)
    Medical Record Number
    Item
    integer
    C1301894 (UMLS CUI [1])
    Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
    Item
    Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
    text
    C0019994 (UMLS CUI [1])
    Item Group
    Contact Information
    Address
    Item
    Address
    text
    C0421449 (UMLS CUI [1])
    Unit number
    Item
    Unit number
    integer
    C0439148 (UMLS CUI [1])
    City
    Item
    City
    text
    C0008848 (UMLS CUI [1])
    State
    Item
    State
    text
    C1442792 (UMLS CUI [1])
    Zip
    Item
    Zip
    integer
    C1521842 (UMLS CUI [1])
    Phone number
    Item
    Phone number
    integer
    C1515258 (UMLS CUI [1])
    Item
    What kind of phone number is it?
    text
    C1515258 (UMLS CUI [1,1])
    C0332307 (UMLS CUI [1,2])
    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
    C1515258 (UMLS CUI [1,1])
    C1523987 (UMLS CUI [1,2])
    Item
    What kind of Phone number is it?
    text
    C1515258 (UMLS CUI [1,1])
    C0332307 (UMLS CUI [1,2])
    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
    C1705961 (UMLS CUI [1])
    Preferred method of contact
    Item
    Preferred method of contact
    text
    C1997600 (UMLS CUI [1])
    Item Group
    Emergency contact
    Name
    Item
    Name
    text
    C0027365 (UMLS CUI [1])
    Address
    Item
    Address
    text
    C0421449 (UMLS CUI [1])
    Unit number
    Item
    integer
    C0439148 (UMLS CUI [1])
    City
    Item
    City
    text
    C0008848 (UMLS CUI [1])
    State
    Item
    State
    text
    C1442792 (UMLS CUI [1])
    Zip
    Item
    Zip
    integer
    C1521842 (UMLS CUI [1])
    Phone Number
    Item
    Phone Number
    integer
    C1515258 (UMLS CUI [1])
    Item
    What kind of phone number is it?
    text
    C1515258 (UMLS CUI [1,1])
    C0332307 (UMLS CUI [1,2])
    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
    C1515258 (UMLS CUI [1,1])
    C1523987 (UMLS CUI [1,2])
    Item
    What kind of phone number is it?
    text
    C1515258 (UMLS CUI [1,1])
    C0332307 (UMLS CUI [1,2])
    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
    C1705961 (UMLS CUI [1])
    Form completed By
    Item
    Form completed By
    text
    Date
    Item
    Date
    date
    C0011008 (UMLS CUI [1])
    Back to the top of the page 

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