ID

16611

Beskrivning

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Device Accountability 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 (4)
  1. 2016-07-26 2016-07-26 -
  2. 2016-11-18 2016-11-18 -
  3. 2021-04-13 2021-04-13 - Dr. rer. medic Philipp Neuhaus
  4. 2021-11-17 2021-11-17 -
Uppladdad den

26 juli 2016

DOI

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Licens

Creative Commons BY-NC 3.0
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Device Accountability Log: CRF Wisconsin Madison

Engelsk

Device Accountability 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

Number of Page
Beskrivning

Number of Page

Datatyp

integer

Total amount of pages
Beskrivning

Total amount of pages

Datatyp

integer

Device Accountability Log: Device Receipt
Beskrivning

Device Accountability Log: Device Receipt

Date Received
Beskrivning

Date Received

Datatyp

date

Batch # or Device Type
Beskrivning

Batch # or Device Type

Datatyp

text

Lot #, Serial #, or Model Number(s)
Beskrivning

Lot #, Serial #, or Model Number(s)

Datatyp

integer

Received by (staff initials)
Beskrivning

Received by (staff initials)

Datatyp

text

Device Accountability Log: Device Use
Beskrivning

Device Accountability Log: Device Use

Date used
Beskrivning

Date used

Datatyp

date

Subject Study ID
Beskrivning

Subject Study ID

Datatyp

integer

Dispensed by (staff initials)
Beskrivning

Dispensed by (staff initials)

Datatyp

text

Device Accountability Log: Device Return/Repair/Destruction
Beskrivning

Device Accountability Log: Device Return/Repair/Destruction

Device Position
Beskrivning

RET = Returned DES = Destroyed REP = Repaired

Datatyp

text

Date of final Device Disposition
Beskrivning

Date of final Device Disposition

Datatyp

date

Reason
Beskrivning

Reason

Datatyp

text

Confirmed by (staff initials)
Beskrivning

Confirmed by (staff initials)

Datatyp

text

Comments
Beskrivning

Comments

Datatyp

text

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Similar models

Device Accountability 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
Number of Page
Item
Number of Page
integer
Total amount of pages
Item
Total amount of pages
integer
Item Group
Device Accountability Log: Device Receipt
Date Received
Item
Date Received
date
Batch # or Device Type
Item
Batch # or Device Type
text
Lot #, Serial #, or Model Number(s)
Item
Lot #, Serial #, or Model Number(s)
integer
Received by (staff initials)
Item
Received by (staff initials)
text
Item Group
Device Accountability Log: Device Use
Date used
Item
Date used
date
Subject Study ID
Item
Subject Study ID
integer
Dispensed by (staff initials)
Item
Dispensed by (staff initials)
text
Item Group
Device Accountability Log: Device Return/Repair/Destruction
Device Position
Item
Device Position
text
Date of final Device Disposition
Item
Date of final Device Disposition
date
Reason
Item
Reason
text
Confirmed by (staff initials)
Item
Confirmed by (staff initials)
text
Comments
Item
Comments
text
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