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ID

16531

Description

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.

Lien

https://ictr.wisc.edu/CaseReptTempt

Mots-clés

Versions (2)
  1. 22/07/2016 22/07/2016 -
  2. 17/11/2016 17/11/2016 -
Téléchargé le

22 juillet 2016

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0
Modèle Commentaires :

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    Demographics: CRF Wisconsin Madison

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    Demographics: CRF Wisconsin Madison

    1 Formulaires  
    Header
    Description

    Header

    PI Name
    Description

    PI Name

    Type de données

    text

    Protocol or IRB Number
    Description

    Protocol or IRB Number

    Type de données

    integer

    Protocol Short Title
    Description

    Protocol Short Title

    Type de données

    text

    Subject Initials
    Description

    Subject Initials

    Type de données

    text

    Subject ID
    Description

    Subject ID

    Type de données

    integer

    Date
    Description

    Date

    Type de données

    date

    Demographics
    Description

    Demographics

    Subject UWHC Medical Record Number
    Description

    Subject UWHC Medical Record Number

    Type de données

    integer

    First Name
    Description

    First Name

    Type de données

    text

    Middle Name (or initial)
    Description

    Middle Name (or initial)

    Type de données

    text

    Last Name
    Description

    Last Name

    Type de données

    text

    Birthdate
    Description

    Birthdate

    Type de données

    date

    Gender
    Description

    Gender

    Type de données

    text

    Ethnicity
    Description

    Ethnicity

    Type de données

    text

    American Indian or Alaska Native
    Description

    Race

    Type de données

    boolean

    Asian
    Description

    Race

    Type de données

    boolean

    Black or African American
    Description

    Race

    Type de données

    boolean

    Native Hawaiian or Other Pacific Islander
    Description

    Race

    Type de données

    boolean

    White or Caucasian
    Description

    Race

    Type de données

    boolean

    Unknown or not Reported
    Description

    Race

    Type de données

    boolean

    Other Medical Record Number(s)
    Description

    Other Medical Record Number(s)

    Medical Record Number
    Description

    Medical Record Number

    Type de données

    integer

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

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

    Type de données

    text

    Contact Information
    Description

    Contact Information

    Address
    Description

    Address

    Type de données

    text

    Unit number
    Description

    Unit number

    Type de données

    integer

    City
    Description

    City

    Type de données

    text

    State
    Description

    State

    Type de données

    text

    Zip
    Description

    Zip

    Type de données

    integer

    Phone number
    Description

    Phone number

    Type de données

    integer

    What kind of phone number is it?
    Description

    Phone number

    Type de données

    text

    Alternate Phone Number
    Description

    Alternate Phone Number

    Type de données

    integer

    What kind of Phone number is it?
    Description

    Alternate Phone Number

    Type de données

    text

    Email address
    Description

    Email address

    Type de données

    text

    Preferred method of contact
    Description

    Preferred method of contact

    Type de données

    text

    Emergency contact
    Description

    Emergency contact

    Name
    Description

    Name

    Type de données

    text

    Address
    Description

    Address

    Type de données

    text

    Unit number
    Description

    Unit number

    Type de données

    integer

    City
    Description

    City

    Type de données

    text

    State
    Description

    State

    Type de données

    text

    Zip
    Description

    Zip

    Type de données

    integer

    Phone Number
    Description

    Phone Number

    Type de données

    integer

    What kind of phone number is it?
    Description

    Phone number

    Type de données

    text

    Alternate Phone Number
    Description

    Alternate Phone Number

    Type de données

    integer

    What kind of phone number is it?
    Description

    Alternate Phone Number

    Type de données

    text

    Email address
    Description

    Email address

    Type de données

    text

    Form completed By
    Description

    Form completed By

    Type de données

    text

    Date
    Description

    Date

    Type de données

    date

    Retour au début de la page

    Similar models

    Demographics: CRF Wisconsin Madison

    1 Formulaires
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    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
    Retour au début de la page 

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