ID

16531

Beskrivning

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.

Länk

https://ictr.wisc.edu/CaseReptTempt

Nyckelord

Versioner (2)
  1. 2016-07-22 2016-07-22 -
  2. 2016-11-17 2016-11-17 -
Uppladdad den

22 juli 2016

DOI

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Licens

Creative Commons BY-NC 3.0
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Demographics: CRF Wisconsin Madison

Engelsk

Demographics: CRF Wisconsin Madison

1 Formulär  
Header
Beskrivning

Header

PI Name
Beskrivning

PI Name

Datatyp

text

Protocol or IRB Number
Beskrivning

Protocol or IRB Number

Datatyp

integer

Protocol Short Title
Beskrivning

Protocol Short Title

Datatyp

text

Subject Initials
Beskrivning

Subject Initials

Datatyp

text

Subject ID
Beskrivning

Subject ID

Datatyp

integer

Date
Beskrivning

Date

Datatyp

date

Demographics
Beskrivning

Demographics

Subject UWHC Medical Record Number
Beskrivning

Subject UWHC Medical Record Number

Datatyp

integer

First Name
Beskrivning

First Name

Datatyp

text

Middle Name (or initial)
Beskrivning

Middle Name (or initial)

Datatyp

text

Last Name
Beskrivning

Last Name

Datatyp

text

Birthdate
Beskrivning

Birthdate

Datatyp

date

Gender
Beskrivning

Gender

Datatyp

text

Ethnicity
Beskrivning

Ethnicity

Datatyp

text

American Indian or Alaska Native
Beskrivning

Race

Datatyp

boolean

Asian
Beskrivning

Race

Datatyp

boolean

Black or African American
Beskrivning

Race

Datatyp

boolean

Native Hawaiian or Other Pacific Islander
Beskrivning

Race

Datatyp

boolean

White or Caucasian
Beskrivning

Race

Datatyp

boolean

Unknown or not Reported
Beskrivning

Race

Datatyp

boolean

Other Medical Record Number(s)
Beskrivning

Other Medical Record Number(s)

Medical Record Number
Beskrivning

Medical Record Number

Datatyp

integer

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

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

Datatyp

text

Contact Information
Beskrivning

Contact Information

Address
Beskrivning

Address

Datatyp

text

Unit number
Beskrivning

Unit number

Datatyp

integer

City
Beskrivning

City

Datatyp

text

State
Beskrivning

State

Datatyp

text

Zip
Beskrivning

Zip

Datatyp

integer

Phone number
Beskrivning

Phone number

Datatyp

integer

What kind of phone number is it?
Beskrivning

Phone number

Datatyp

text

Alternate Phone Number
Beskrivning

Alternate Phone Number

Datatyp

integer

What kind of Phone number is it?
Beskrivning

Alternate Phone Number

Datatyp

text

Email address
Beskrivning

Email address

Datatyp

text

Preferred method of contact
Beskrivning

Preferred method of contact

Datatyp

text

Emergency contact
Beskrivning

Emergency contact

Name
Beskrivning

Name

Datatyp

text

Address
Beskrivning

Address

Datatyp

text

Unit number
Beskrivning

Unit number

Datatyp

integer

City
Beskrivning

City

Datatyp

text

State
Beskrivning

State

Datatyp

text

Zip
Beskrivning

Zip

Datatyp

integer

Phone Number
Beskrivning

Phone Number

Datatyp

integer

What kind of phone number is it?
Beskrivning

Phone number

Datatyp

text

Alternate Phone Number
Beskrivning

Alternate Phone Number

Datatyp

integer

What kind of phone number is it?
Beskrivning

Alternate Phone Number

Datatyp

text

Email address
Beskrivning

Email address

Datatyp

text

Form completed By
Beskrivning

Form completed By

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

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Similar models

Demographics: CRF Wisconsin Madison

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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