ID

16538

Beskrivning

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.

Länk

https://ictr.wisc.edu/CaseReptTempt

Nyckelord

Versioner (2)
  1. 2016-07-23 2016-07-23 -
  2. 2016-11-17 2016-11-17 -
Uppladdad den

23 juli 2016

DOI

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Licens

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

Engelsk

Concomitant Medication Log: 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

Number of Page
Beskrivning

Number of Page

Datatyp

integer

Total amount of pages
Beskrivning

Total amount of pages

Datatyp

integer

Concomitant Medication Log
Beskrivning

Concomitant Medication Log

#
Beskrivning

#

Datatyp

integer

Medication/ Non-drug Therapy
Beskrivning

Medication/ Non-drug Therapy

Datatyp

text

Indication
Beskrivning

Indication

Datatyp

text

Dose (per admin)
Beskrivning

Dose (per admin)

Datatyp

float

Dose Units
Beskrivning

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

Datatyp

text

Schedule/Frequency
Beskrivning

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

Datatyp

text

Dose Form
Beskrivning

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

Datatyp

text

Route of Administration
Beskrivning

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

Datatyp

text

Start Date
Beskrivning

Start Date

Datatyp

date

End Date
Beskrivning

End Date

Datatyp

date

Baseline Med
Beskrivning

Baseline Med

Datatyp

boolean

Continuing at end of study
Beskrivning

Continuing at end of study

Datatyp

boolean

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Similar models

Concomitant Medication Log: 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
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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