ID

16875

Description

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Demographics Form. 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

DOI

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License

Creative Commons BY-NC 3.0
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Demographics Form: UIC Quality Improvement CRF

English

Demographics Form: UIC Quality Improvement CRF

1 forms  
Demographics Form
Description

Demographics Form

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. Gender
Description

1. Gender

Data type

text

2. Date of Birth
Description

2. Date of Birth

Data type

date

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

3. Race

Data type

text

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

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

Data type

text

5. Informed Consent Process
Description

5. Informed Consent Process

Data type

text

5. Date (if informed consent signed)
Description

5. Date

Data type

date

Completed by (initials)
Description

Completed by

Data type

text

Date completed
Description

Date completed

Data type

date

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Similar models

Demographics Form: UIC Quality Improvement CRF

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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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