ID

16616

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Drug Dispension & 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.

Lien

https://ictr.wisc.edu/CaseReptTempt

Mots-clés

Versions (2)
  1. 26/07/2016 26/07/2016 -
  2. 18/11/2016 18/11/2016 -
Téléchargé le

26 juillet 2016

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0
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Drug Dispension & Accountability Log: CRF Wisconsin Madison

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Drug Dispension & Accountability Log: 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

Number of Pages
Description

Number of Pages

Type de données

integer

Total Number of Pages
Description

Total Number of Pages

Type de données

integer

Drug Dispensation & Accountability Log
Description

Drug Dispensation & Accountability Log

Subject Initials
Description

Subject Initials

Type de données

text

Subject Study ID
Description

Subject Study ID

Type de données

integer

Lot Number(s)
Description

Lot Number(s)

Type de données

integer

Unit Dose (e.g. mg)
Description

Unit Dose

Type de données

text

Drug Dispensation & Accountability Log: Dispensed to Subject
Description

Drug Dispensation & Accountability Log: Dispensed to Subject

Number of Containers Dispensed
Description

Number of Containers Dispensed

Type de données

integer

Number of Units Dispensed
Description

Number of Units Dispensed

Type de données

integer

Date Dispensed
Description

Date Dispensed

Type de données

date

Dispensed by (staff initials)
Description

Dispensed by (staff initials)

Type de données

text

Drug Dispensation & Accountability Log: Returned by Subject
Description

Drug Dispensation & Accountability Log: Returned by Subject

Number of Containers Returned
Description

Number of Containers Returned

Type de données

integer

Number of units returned
Description

Number of units returned

Type de données

integer

Date Returned
Description

Date Returned

Type de données

date

Verified by (staff initials)
Description

Verified by (staff initials)

Type de données

text

Drug Dispensation & Accountability Log: Compliance
Description

Drug Dispensation & Accountability Log: Compliance

Expected number of units to be used/taken
Description

Expected number of units to be used/taken

Type de données

integer

Actual number of units used/taken
Description

Actual number of units used/taken

Type de données

integer

% compliance
Description

% compliance

Type de données

integer

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Similar models

Drug Dispension & Accountability Log: 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
Number of Pages
Item
Number of Pages
integer
Total Number of Pages
Item
Total Number of Pages
integer
Item Group
Drug Dispensation & Accountability Log
Subject Initials
Item
Subject Initials
text
Subject Study ID
Item
Subject Study ID
integer
Lot Number(s)
Item
Lot Number(s)
integer
Unit Dose
Item
Unit Dose (e.g. mg)
text
Item Group
Drug Dispensation & Accountability Log: Dispensed to Subject
Number of Containers Dispensed
Item
Number of Containers Dispensed
integer
Number of Units Dispensed
Item
Number of Units Dispensed
integer
Date Dispensed
Item
Date Dispensed
date
Dispensed by (staff initials)
Item
Dispensed by (staff initials)
text
Item Group
Drug Dispensation & Accountability Log: Returned by Subject
Number of Containers Returned
Item
Number of Containers Returned
integer
Number of units returned
Item
Number of units returned
integer
Date Returned
Item
Date Returned
date
Verified by (staff initials)
Item
Verified by (staff initials)
text
Item Group
Drug Dispensation & Accountability Log: Compliance
Expected number of units to be used/taken
Item
Expected number of units to be used/taken
integer
Actual number of units used/taken
Item
Actual number of units used/taken
integer
% compliance
Item
% compliance
integer
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