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ID

16870

Description

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Inclusion/Exclusion Criteria. 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

  1. 8/11/16 8/11/16 -
Uploaded on

August 11, 2016

DOI

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License

Creative Commons BY-NC 3.0

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    Inclusion/Exclusion Criteria: UIC Quality Improvement CRF

    Inclusion/Exclusion Criteria: UIC Quality Improvement CRF

    General Information
    Description

    General Information

    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

    Study Visit
    Description

    Study Visit

    Data type

    text

    Inclusion Criteria
    Description

    Inclusion Criteria

    Inclusion Description
    Description

    Inclusion Description

    Data type

    text

    Inclusion description fulfilled
    Description

    Inclusion Description

    Data type

    boolean

    Exclusion Criteria
    Description

    Exclusion Criteria

    Exclusion Description
    Description

    Exclusion Description

    Data type

    text

    Exclusion description fulfilled
    Description

    Exclusion Description

    Data type

    boolean

    Results
    Description

    Results

    Did the subject meet the eligibility requirements for this study?
    Description

    Did the subject meet the eligibility requirements for this study?

    Data type

    boolean

    Signature
    Description

    Signature

    Data type

    text

    Date
    Description

    Date

    Data type

    date

    Printed Name
    Description

    Printed Name

    Data type

    text

    Similar models

    Inclusion/Exclusion Criteria: UIC Quality Improvement CRF

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    General Information
    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
    Study Visit
    text
    Code List
    Study Visit
    CL Item
    Screening (1)
    CL Item
    Baseline (2)
    Item Group
    Inclusion Criteria
    Inclusion Description
    Item
    Inclusion Description
    text
    Inclusion Description
    Item
    Inclusion description fulfilled
    boolean
    Item Group
    Exclusion Criteria
    Exclusion Description
    Item
    Exclusion Description
    text
    Exclusion Description
    Item
    Exclusion description fulfilled
    boolean
    Item Group
    Results
    Did the subject meet the eligibility requirements for this study?
    Item
    Did the subject meet the eligibility requirements for this study?
    boolean
    Signature
    Item
    Signature
    text
    Date
    Item
    Date
    date
    Printed Name
    Item
    Printed Name
    text

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