ID

16538

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Concomitant Medication Log. 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

Keywords

Versions (2)
  1. 7/23/16 7/23/16 -
  2. 11/17/16 11/17/16 -
Uploaded on

July 23, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Concomitant Medication Log: CRF Wisconsin Madison

English

Concomitant Medication Log: CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Protocol Short Title
Description

Protocol Short Title

Data type

text

Subject Initials
Description

Subject Initials

Data type

text

Subject ID
Description

Subject ID

Data type

integer

Number of Page
Description

Number of Page

Data type

integer

Total amount of pages
Description

Total amount of pages

Data type

integer

Concomitant Medication Log
Description

Concomitant Medication Log

#
Description

#

Data type

integer

Medication/ Non-drug Therapy
Description

Medication/ Non-drug Therapy

Data type

text

Indication
Description

Indication

Data type

text

Dose (per admin)
Description

Dose (per admin)

Data type

float

Dose Units
Description

1= g 2= mg 3= ug 4= L 5= mL 6= IU 7= Other

Data type

text

Schedule/Frequency
Description

1= QD (once a day) 2= BID (twice a day) 3= TID (three times a day) 4= QID (four times a day) 5= QOD (every other day) 6= QM (every month) 7= QOM (every other month) 8= QH (every hour) 9= AC (before meals) 10= PC (after meals) 11= PRN (as needed) 12= Other

Data type

text

Dose Form
Description

1= Tablet 2= Capsule 3= Ointment 4=Suppository 5=Aerosol 6=Spray 7=Suspension 8= Patch 9=Gas 10=Gel 11=Cream 12=Powder

Data type

text

Route of Administration
Description

1= Oral 2= Topical 3= Subcutaneous 4= Intradermal 5= Transdermal 6= Intraocular 7= Intramuscular 8= Inhalation 9= Intravenous 10= Intraperitoneal 11= Nasal 12= Vaginal 13= Rectal 14= Other

Data type

text

Start Date
Description

Start Date

Data type

date

End Date
Description

End Date

Data type

date

Baseline Med
Description

Baseline Med

Data type

boolean

Continuing at end of study
Description

Continuing at end of study

Data type

boolean

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Similar models

Concomitant Medication Log: CRF Wisconsin Madison

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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
Number of Page
Item
Number of Page
integer
Total amount of pages
Item
Total amount of pages
integer
Item Group
Concomitant Medication Log
#
Item
#
integer
Medication/ Non-drug Therapy
Item
Medication/ Non-drug Therapy
text
Indication
Item
Indication
text
Dose (per admin)
Item
Dose (per admin)
float
Dose Units
Item
Dose Units
text
Schedule/Frequency
Item
Schedule/Frequency
text
Dose Form
Item
Dose Form
text
Route of Administration
Item
Route of Administration
text
Start Date
Item
Start Date
date
End Date
Item
End Date
date
Baseline Med
Item
Baseline Med
boolean
Continuing at end of study
Item
Continuing at end of study
boolean
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