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Demographics Form: UIC Quality Improvement CRF

1 moduli  
Demographics Form
Descrizione

Demographics Form

Protocol Title
Descrizione

Protocol Title

Tipo di dati

text

Site Number
Descrizione

Site Number

Tipo di dati

integer

Subject ID
Descrizione

Subject ID

Tipo di dati

integer

Visit Date
Descrizione

Visit Date

Tipo di dati

date

1. Gender
Descrizione

1. Gender

Tipo di dati

text

2. Date of Birth
Descrizione

2. Date of Birth

Tipo di dati

date

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

3. Race

Tipo di dati

text

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

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

Tipo di dati

text

5. Informed Consent Process
Descrizione

5. Informed Consent Process

Tipo di dati

text

5. Date (if informed consent signed)
Descrizione

5. Date

Tipo di dati

date

Completed by (initials)
Descrizione

Completed by

Tipo di dati

text

Date completed
Descrizione

Date completed

Tipo di dati

date

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Similar models

Demographics Form: UIC Quality Improvement CRF

1 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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