ID

16864

Beskrivning

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.

Länk

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

Nyckelord

Versioner (1)
  1. 2016-08-11 2016-08-11 -
Uppladdad den

11 augusti 2016

DOI

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Licens

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

Engelsk

Visit Checklist: UIC Quality Improvement CRF

1 Formulär  
Visit Checklist
Beskrivning

Visit Checklist

Protocol Title
Beskrivning

Protocol Title

Datatyp

text

Site Number
Beskrivning

Site Number

Datatyp

integer

Subject ID
Beskrivning

Subject ID

Datatyp

integer

Visit Date
Beskrivning

Visit Date

Datatyp

date

1. Did the subject attend this visit?
Beskrivning

1. Attendance

Datatyp

text

2. Study Visit: Date of Informed Consent Signed
Beskrivning

2. Study Visit

Datatyp

date

Study Visit: Demographics
Beskrivning

Study Visit

Datatyp

boolean

Study Visit: Medical History
Beskrivning

Study Visit

Datatyp

boolean

Study Visit: Vital Signs
Beskrivning

Study Visit

Datatyp

boolean

Study Visit: Physical Exam
Beskrivning

Study Visit

Datatyp

boolean

Study Visit: Prior and Concomitant Medication
Beskrivning

Study Visit

Datatyp

boolean

Study Visit: Inclusion/Exclusion Criteria
Beskrivning

Study Visit

Datatyp

boolean

Study Visit: Randomization
Beskrivning

Study Visit

Datatyp

boolean

Study Visit Enrollment
Beskrivning

Study Visit

Datatyp

boolean

3. Is the subject continuing in the study?
Beskrivning

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

Datatyp

boolean

Comments
Beskrivning

Comments

Datatyp

text

Completed by (initials)
Beskrivning

Completed by

Datatyp

text

Date completed
Beskrivning

Date completed

Datatyp

date

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Similar models

Visit Checklist: UIC Quality Improvement CRF

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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