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16531

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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.

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https://ictr.wisc.edu/CaseReptTempt

Nyckelord

Versioner (2)
  1. 22.07.16 22.07.16 -
  2. 17.11.16 17.11.16 -
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22. Juli 2016

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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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