ID

16531

Descripción

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

Palabras clave

Versiones (2)
  1. 22/7/16 22/7/16 -
  2. 17/11/16 17/11/16 -
Subido en

22 de julio de 2016

DOI

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Licencia

Creative Commons BY-NC 3.0
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Demographics: CRF Wisconsin Madison

Inglés

Demographics: CRF Wisconsin Madison

1 formularios  
Header
Descripción

Header

PI Name
Descripción

PI Name

Tipo de datos

text

Protocol or IRB Number
Descripción

Protocol or IRB Number

Tipo de datos

integer

Protocol Short Title
Descripción

Protocol Short Title

Tipo de datos

text

Subject Initials
Descripción

Subject Initials

Tipo de datos

text

Subject ID
Descripción

Subject ID

Tipo de datos

integer

Date
Descripción

Date

Tipo de datos

date

Demographics
Descripción

Demographics

Subject UWHC Medical Record Number
Descripción

Subject UWHC Medical Record Number

Tipo de datos

integer

First Name
Descripción

First Name

Tipo de datos

text

Middle Name (or initial)
Descripción

Middle Name (or initial)

Tipo de datos

text

Last Name
Descripción

Last Name

Tipo de datos

text

Birthdate
Descripción

Birthdate

Tipo de datos

date

Gender
Descripción

Gender

Tipo de datos

text

Ethnicity
Descripción

Ethnicity

Tipo de datos

text

American Indian or Alaska Native
Descripción

Race

Tipo de datos

boolean

Asian
Descripción

Race

Tipo de datos

boolean

Black or African American
Descripción

Race

Tipo de datos

boolean

Native Hawaiian or Other Pacific Islander
Descripción

Race

Tipo de datos

boolean

White or Caucasian
Descripción

Race

Tipo de datos

boolean

Unknown or not Reported
Descripción

Race

Tipo de datos

boolean

Other Medical Record Number(s)
Descripción

Other Medical Record Number(s)

Medical Record Number
Descripción

Medical Record Number

Tipo de datos

integer

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

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

Tipo de datos

text

Contact Information
Descripción

Contact Information

Address
Descripción

Address

Tipo de datos

text

Unit number
Descripción

Unit number

Tipo de datos

integer

City
Descripción

City

Tipo de datos

text

State
Descripción

State

Tipo de datos

text

Zip
Descripción

Zip

Tipo de datos

integer

Phone number
Descripción

Phone number

Tipo de datos

integer

What kind of phone number is it?
Descripción

Phone number

Tipo de datos

text

Alternate Phone Number
Descripción

Alternate Phone Number

Tipo de datos

integer

What kind of Phone number is it?
Descripción

Alternate Phone Number

Tipo de datos

text

Email address
Descripción

Email address

Tipo de datos

text

Preferred method of contact
Descripción

Preferred method of contact

Tipo de datos

text

Emergency contact
Descripción

Emergency contact

Name
Descripción

Name

Tipo de datos

text

Address
Descripción

Address

Tipo de datos

text

Unit number
Descripción

Unit number

Tipo de datos

integer

City
Descripción

City

Tipo de datos

text

State
Descripción

State

Tipo de datos

text

Zip
Descripción

Zip

Tipo de datos

integer

Phone Number
Descripción

Phone Number

Tipo de datos

integer

What kind of phone number is it?
Descripción

Phone number

Tipo de datos

text

Alternate Phone Number
Descripción

Alternate Phone Number

Tipo de datos

integer

What kind of phone number is it?
Descripción

Alternate Phone Number

Tipo de datos

text

Email address
Descripción

Email address

Tipo de datos

text

Form completed By
Descripción

Form completed By

Tipo de datos

text

Date
Descripción

Date

Tipo de datos

date

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Similar models

Demographics: CRF Wisconsin Madison

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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