Engelsk

Demographics Form: UIC Quality Improvement CRF

1 Formulär  
Demographics Form
Beskrivning

Demographics Form

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. Gender
Beskrivning

1. Gender

Datatyp

text

2. Date of Birth
Beskrivning

2. Date of Birth

Datatyp

date

3. Race (select the one with which you most closely identify)
Beskrivning

3. Race

Datatyp

text

4. Ethnicity (Select one with which you most closely identify)
Beskrivning

4. Ethnicity (Select one with which you most closely identify)

Datatyp

text

5. Informed Consent Process
Beskrivning

5. Informed Consent Process

Datatyp

text

5. Date (if informed consent signed)
Beskrivning

5. Date

Datatyp

date

Completed by (initials)
Beskrivning

Completed by

Datatyp

text

Date completed
Beskrivning

Date completed

Datatyp

date

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Demographics Form: UIC Quality Improvement CRF

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Demographics Form
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. Gender
text
1. Gender
Code List
1. Gender
CL Item
Female (1)
CL Item
Male (2)
2. Date of Birth
Item
2. Date of Birth
date
Item
3. Race (select the one with which you most closely identify)
text
3. Race
Code List
3. Race (select the one with which you most closely identify)
CL Item
American Indian or Alaska Native (1)
CL Item
Asian (2)
CL Item
Black or African-American (3)
CL Item
Native Hawaiian or Other Pacific Islander (4)
CL Item
White (5)
CL Item
More than one race (6)
CL Item
Unknown or not reported (7)
Item
4. Ethnicity (Select one with which you most closely identify)
text
4. Ethnicity (Select one with which you most closely identify)
Code List
4. Ethnicity (Select one with which you most closely identify)
CL Item
Hispanic or Latino (1)
CL Item
Not Hispanic or Latino (2)
CL Item
Unknown or not reported (3)
Item
5. Informed Consent Process
text
5. Informed Consent Process
Code List
5. Informed Consent Process
CL Item
Waiver of consent granted for recruitment purposes (1)
CL Item
Informed consent signed: ____(mm/dd/yy) (2)
5. Date
Item
5. Date (if informed consent signed)
date
Completed by
Item
Completed by (initials)
text
Date completed
Item
Date completed
date
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