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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

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Creative Commons BY-NC 3.0
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    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 

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