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ID

16864

Description

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Visit Checklist. QIP Case Report Forms, UIC Quality Improvement CRF, Office of the Vice Chancellor for Research. Center for Clinical and Translational Science, UIC University of Illinois at Chicago.

Link

http://research.uic.edu/qip/toolbox/case-report-forms-crf

Keywords

Versions (1)
  1. 8/11/16 8/11/16 -
Uploaded on

August 11, 2016

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License

Creative Commons BY-NC 3.0
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    Visit Checklist: UIC Quality Improvement CRF

    English

    Visit Checklist: UIC Quality Improvement CRF

    1 forms  
    Visit Checklist
    Description

    Visit Checklist

    Protocol Title
    Description

    Protocol Title

    Data type

    text

    Site Number
    Description

    Site Number

    Data type

    integer

    Subject ID
    Description

    Subject ID

    Data type

    integer

    Visit Date
    Description

    Visit Date

    Data type

    date

    1. Did the subject attend this visit?
    Description

    1. Attendance

    Data type

    text

    2. Study Visit: Date of Informed Consent Signed
    Description

    2. Study Visit

    Data type

    date

    Study Visit: Demographics
    Description

    Study Visit

    Data type

    boolean

    Study Visit: Medical History
    Description

    Study Visit

    Data type

    boolean

    Study Visit: Vital Signs
    Description

    Study Visit

    Data type

    boolean

    Study Visit: Physical Exam
    Description

    Study Visit

    Data type

    boolean

    Study Visit: Prior and Concomitant Medication
    Description

    Study Visit

    Data type

    boolean

    Study Visit: Inclusion/Exclusion Criteria
    Description

    Study Visit

    Data type

    boolean

    Study Visit: Randomization
    Description

    Study Visit

    Data type

    boolean

    Study Visit Enrollment
    Description

    Study Visit

    Data type

    boolean

    3. Is the subject continuing in the study?
    Description

    If yes, remember to complete a Study Completion Form. If no, schedule next visit.

    Data type

    boolean

    Comments
    Description

    Comments

    Data type

    text

    Completed by (initials)
    Description

    Completed by

    Data type

    text

    Date completed
    Description

    Date completed

    Data type

    date

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    Similar models

    Visit Checklist: UIC Quality Improvement CRF

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Visit Checklist
    Protocol Title
    Item
    Protocol Title
    text
    Site Number
    Item
    Site Number
    integer
    Subject ID
    Item
    Subject ID
    integer
    Visit Date
    Item
    Visit Date
    date
    Item
    1. Did the subject attend this visit?
    text
    Attendance
    Code List
    1. Did the subject attend this visit?
    CL Item
    Yes (If yes, continue) (1)
    CL Item
    No (If no, enter comments below) (2)
    2. Study Visit
    Item
    2. Study Visit: Date of Informed Consent Signed
    date
    Study Visit
    Item
    Study Visit: Demographics
    boolean
    Study Visit
    Item
    Study Visit: Medical History
    boolean
    Study Visit
    Item
    Study Visit: Vital Signs
    boolean
    Study Visit
    Item
    Study Visit: Physical Exam
    boolean
    Study Visit
    Item
    Study Visit: Prior and Concomitant Medication
    boolean
    Study Visit
    Item
    Study Visit: Inclusion/Exclusion Criteria
    boolean
    Study Visit
    Item
    Study Visit: Randomization
    boolean
    Study Visit
    Item
    Study Visit Enrollment
    boolean
    3. Is the subject continuing in the study?
    Item
    3. Is the subject continuing in the study?
    boolean
    Comments
    Item
    Comments
    text
    Completed by
    Item
    Completed by (initials)
    text
    Date completed
    Item
    Date completed
    date
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