ID

16531

Beschreibung

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

Stichworte

Versionen (2)
  1. 22.07.16 22.07.16 -
  2. 17.11.16 17.11.16 -
Hochgeladen am

22. Juli 2016

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Demographics: CRF Wisconsin Madison

Englisch

Demographics: CRF Wisconsin Madison

1 Formulare  
Header
Beschreibung

Header

PI Name
Beschreibung

PI Name

Datentyp

text

Protocol or IRB Number
Beschreibung

Protocol or IRB Number

Datentyp

integer

Protocol Short Title
Beschreibung

Protocol Short Title

Datentyp

text

Subject Initials
Beschreibung

Subject Initials

Datentyp

text

Subject ID
Beschreibung

Subject ID

Datentyp

integer

Date
Beschreibung

Date

Datentyp

date

Demographics
Beschreibung

Demographics

Subject UWHC Medical Record Number
Beschreibung

Subject UWHC Medical Record Number

Datentyp

integer

First Name
Beschreibung

First Name

Datentyp

text

Middle Name (or initial)
Beschreibung

Middle Name (or initial)

Datentyp

text

Last Name
Beschreibung

Last Name

Datentyp

text

Birthdate
Beschreibung

Birthdate

Datentyp

date

Gender
Beschreibung

Gender

Datentyp

text

Ethnicity
Beschreibung

Ethnicity

Datentyp

text

American Indian or Alaska Native
Beschreibung

Race

Datentyp

boolean

Asian
Beschreibung

Race

Datentyp

boolean

Black or African American
Beschreibung

Race

Datentyp

boolean

Native Hawaiian or Other Pacific Islander
Beschreibung

Race

Datentyp

boolean

White or Caucasian
Beschreibung

Race

Datentyp

boolean

Unknown or not Reported
Beschreibung

Race

Datentyp

boolean

Other Medical Record Number(s)
Beschreibung

Other Medical Record Number(s)

Medical Record Number
Beschreibung

Medical Record Number

Datentyp

integer

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

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

Datentyp

text

Contact Information
Beschreibung

Contact Information

Address
Beschreibung

Address

Datentyp

text

Unit number
Beschreibung

Unit number

Datentyp

integer

City
Beschreibung

City

Datentyp

text

State
Beschreibung

State

Datentyp

text

Zip
Beschreibung

Zip

Datentyp

integer

Phone number
Beschreibung

Phone number

Datentyp

integer

What kind of phone number is it?
Beschreibung

Phone number

Datentyp

text

Alternate Phone Number
Beschreibung

Alternate Phone Number

Datentyp

integer

What kind of Phone number is it?
Beschreibung

Alternate Phone Number

Datentyp

text

Email address
Beschreibung

Email address

Datentyp

text

Preferred method of contact
Beschreibung

Preferred method of contact

Datentyp

text

Emergency contact
Beschreibung

Emergency contact

Name
Beschreibung

Name

Datentyp

text

Address
Beschreibung

Address

Datentyp

text

Unit number
Beschreibung

Unit number

Datentyp

integer

City
Beschreibung

City

Datentyp

text

State
Beschreibung

State

Datentyp

text

Zip
Beschreibung

Zip

Datentyp

integer

Phone Number
Beschreibung

Phone Number

Datentyp

integer

What kind of phone number is it?
Beschreibung

Phone number

Datentyp

text

Alternate Phone Number
Beschreibung

Alternate Phone Number

Datentyp

integer

What kind of phone number is it?
Beschreibung

Alternate Phone Number

Datentyp

text

Email address
Beschreibung

Email address

Datentyp

text

Form completed By
Beschreibung

Form completed By

Datentyp

text

Date
Beschreibung

Date

Datentyp

date

Zum Seitenanfang zurückkehren

Ähnliche Modelle

Demographics: CRF Wisconsin Madison

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

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video