Informatie:
Fout:
ID
16875
Beschrijving
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
Trefwoorden
Versies (1)
- 11-08-16 11-08-16 -
Geüploaded op
11 augustus 2016
DOI
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Licentie
Creative Commons BY-NC 3.0
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Demographics Form: UIC Quality Improvement CRF
Demographics Form: UIC Quality Improvement CRF
- StudyEvent: ODM
Similar models
Demographics Form: UIC Quality Improvement CRF
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Protocol Title
Item
Protocol Title
text
Site Number
Item
Site Number
integer
Subject ID
Item
Subject ID
integer
Visit Date
Item
Visit Date
date
CL Item
Female (1)
CL Item
Male (2)
2. Date of Birth
Item
2. Date of Birth
date
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
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)
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