ID

16531

Beschrijving

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

Trefwoorden

Versies (2)
  1. 22-07-16 22-07-16 -
  2. 17-11-16 17-11-16 -
Geüploaded op

22 juli 2016

DOI

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Licentie

Creative Commons BY-NC 3.0
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Demographics: CRF Wisconsin Madison

Engels

Demographics: CRF Wisconsin Madison

1 Formulieren  
Header
Beschrijving

Header

PI Name
Beschrijving

PI Name

Datatype

text

Protocol or IRB Number
Beschrijving

Protocol or IRB Number

Datatype

integer

Protocol Short Title
Beschrijving

Protocol Short Title

Datatype

text

Subject Initials
Beschrijving

Subject Initials

Datatype

text

Subject ID
Beschrijving

Subject ID

Datatype

integer

Date
Beschrijving

Date

Datatype

date

Demographics
Beschrijving

Demographics

Subject UWHC Medical Record Number
Beschrijving

Subject UWHC Medical Record Number

Datatype

integer

First Name
Beschrijving

First Name

Datatype

text

Middle Name (or initial)
Beschrijving

Middle Name (or initial)

Datatype

text

Last Name
Beschrijving

Last Name

Datatype

text

Birthdate
Beschrijving

Birthdate

Datatype

date

Gender
Beschrijving

Gender

Datatype

text

Ethnicity
Beschrijving

Ethnicity

Datatype

text

American Indian or Alaska Native
Beschrijving

Race

Datatype

boolean

Asian
Beschrijving

Race

Datatype

boolean

Black or African American
Beschrijving

Race

Datatype

boolean

Native Hawaiian or Other Pacific Islander
Beschrijving

Race

Datatype

boolean

White or Caucasian
Beschrijving

Race

Datatype

boolean

Unknown or not Reported
Beschrijving

Race

Datatype

boolean

Other Medical Record Number(s)
Beschrijving

Other Medical Record Number(s)

Medical Record Number
Beschrijving

Medical Record Number

Datatype

integer

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

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

Datatype

text

Contact Information
Beschrijving

Contact Information

Address
Beschrijving

Address

Datatype

text

Unit number
Beschrijving

Unit number

Datatype

integer

City
Beschrijving

City

Datatype

text

State
Beschrijving

State

Datatype

text

Zip
Beschrijving

Zip

Datatype

integer

Phone number
Beschrijving

Phone number

Datatype

integer

What kind of phone number is it?
Beschrijving

Phone number

Datatype

text

Alternate Phone Number
Beschrijving

Alternate Phone Number

Datatype

integer

What kind of Phone number is it?
Beschrijving

Alternate Phone Number

Datatype

text

Email address
Beschrijving

Email address

Datatype

text

Preferred method of contact
Beschrijving

Preferred method of contact

Datatype

text

Emergency contact
Beschrijving

Emergency contact

Name
Beschrijving

Name

Datatype

text

Address
Beschrijving

Address

Datatype

text

Unit number
Beschrijving

Unit number

Datatype

integer

City
Beschrijving

City

Datatype

text

State
Beschrijving

State

Datatype

text

Zip
Beschrijving

Zip

Datatype

integer

Phone Number
Beschrijving

Phone Number

Datatype

integer

What kind of phone number is it?
Beschrijving

Phone number

Datatype

text

Alternate Phone Number
Beschrijving

Alternate Phone Number

Datatype

integer

What kind of phone number is it?
Beschrijving

Alternate Phone Number

Datatype

text

Email address
Beschrijving

Email address

Datatype

text

Form completed By
Beschrijving

Form completed By

Datatype

text

Date
Beschrijving

Date

Datatype

date

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Similar models

Demographics: CRF Wisconsin Madison

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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