ID

16636

Beskrivning

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Subject Deviation/Violation 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 (3)
  1. 2016-07-27 2016-07-27 -
  2. 2016-11-20 2016-11-20 -
  3. 2018-06-20 2018-06-20 - Julian Varghese
Uppladdad den

27 juli 2016

DOI

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Licens

Creative Commons BY-NC 3.0
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Subject Deviation/Violation Log: CRF Wisconsin Madison

Engelsk

Subject Deviation/Violation 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 Pages
Beskrivning

Number of Pages

Datatyp

integer

Total Number of Pages
Beskrivning

Total Number of Pages

Datatyp

integer

Deviation Tracking Log
Beskrivning

Deviation Tracking Log

#
Beskrivning

#

Datatyp

integer

Deviation Start Date
Beskrivning

Deviation Start Date

Datatyp

date

Deviation Ende Date
Beskrivning

Deviation End Date

Datatyp

date

Deviation Description
Beskrivning

Deviation Description

Datatyp

text

Deviation Category
Beskrivning

1= Consent Deviation 2= Drug/Device Administration Deviation 3= Enrollment Deviation 4= Procedural Deviation 5= Other (describe)

Datatyp

text

Does the Deviation Impact Subject Safety
Beskrivning

If one or more is answered yes for any deviation, it must be reported to the IRB promptly (14 business days from notification of or becoming aware of the event). Please refer to the HSIRB Reportable Event guidance for additional information.

Datatyp

text

Does the Deviation Affect Data Integrity
Beskrivning

If one or more is answered yes for any deviation, it must be reported to the IRB promptly (14 business days from notification of or becoming aware of the event). Please refer to the HSIRB Reportable Event guidance for additional information.

Datatyp

text

Does the Deviation Affect Subject´s Willingness to participate?
Beskrivning

If one or more is answered yes for any deviation, it must be reported to the IRB promptly (14 business days from notification of or becoming aware of the event). Please refer to the HSIRB Reportable Event guidance for additional information.

Datatyp

text

Reported to IRB
Beskrivning

Reported to IRB

Datatyp

date

Reported to IRB: Not Applicable
Beskrivning

Reported to IRB

Datatyp

boolean

PI Initials
Beskrivning

PI Initials

Datatyp

text

Date of PI Initials
Beskrivning

Date of PI Initials

Datatyp

date

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Similar models

Subject Deviation/Violation 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 Pages
Item
Number of Pages
integer
Total Number of Pages
Item
Total Number of Pages
integer
Item Group
Deviation Tracking Log
#
Item
#
integer
Deviation Start Date
Item
Deviation Start Date
date
Deviation End Date
Item
Deviation Ende Date
date
Deviation Description
Item
Deviation Description
text
Deviation Category
Item
Deviation Category
text
Item
Does the Deviation Impact Subject Safety
text
Impact Subject Safety
Code List
Does the Deviation Impact Subject Safety
CL Item
Yes (1)
CL Item
No (2)
CL Item
Not Applicable (3)
Item
Does the Deviation Affect Data Integrity
text
Affect Data Integrity
Code List
Does the Deviation Affect Data Integrity
CL Item
Yes (1)
CL Item
No (2)
CL Item
Not Applicable (3)
Item
Does the Deviation Affect Subject´s Willingness to participate?
text
Affect Subject´s Willingness to Participate
Code List
Does the Deviation Affect Subject´s Willingness to participate?
CL Item
Yes (1)
CL Item
No (2)
CL Item
Not Applicable (3)
Reported to IRB
Item
Reported to IRB
date
Reported to IRB
Item
Reported to IRB: Not Applicable
boolean
PI Initials
Item
PI Initials
text
Date of PI Initials
Item
Date of PI Initials
date
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