ID

16963

Descripción

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

Palabras clave

Versiones (1)
  1. 17/8/16 17/8/16 -
Subido en

17 de agosto de 2016

DOI

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Licencia

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

Inglés

Social History Form: UIC Quality Improvement CRF

1 formularios  
General Information
Descripción

General Information

Protocol Title
Descripción

Protocol Title

Tipo de datos

text

Site Number
Descripción

Site Number

Tipo de datos

integer

Subject ID
Descripción

Subject ID

Tipo de datos

integer

Visit Date
Descripción

Visit Date

Tipo de datos

date

Study Visit
Descripción

Study Visit

Tipo de datos

text

Social History Form
Descripción

Social History Form

1. Highest Level of Education
Descripción

1. Highest Level of Education

Tipo de datos

text

2. Occupation
Descripción

2. Occupation

Tipo de datos

text

Occupation
Descripción

Occupation

Tipo de datos

text

Occupation: If retired, please specify date
Descripción

Occupation

Tipo de datos

date

3a. Language(s) in which subject is fluent: English
Descripción

3a. Language

Tipo de datos

boolean

Language(s) in which subject is fluent: Spanish
Descripción

Language

Tipo de datos

boolean

Language(s) in which subject is fluent: Chinese
Descripción

Language

Tipo de datos

boolean

Language(s) in which subject is fluent: Tagalog
Descripción

Language

Tipo de datos

boolean

Language(s) in which subject is fluent: Korean
Descripción

Language

Tipo de datos

boolean

Language(s) in which subject is fluent: Russian
Descripción

Language

Tipo de datos

boolean

Language(s) in which subject is fluent: Polish
Descripción

Language

Tipo de datos

boolean

Language(s) in which subject is fluent: Other
Descripción

Language

Tipo de datos

boolean

If Other, please specify
Descripción

Language

Tipo de datos

text

3b. Language in which subject requests study visits to be conducted
Descripción

3b. Language in which subject requests study visits to be conducted

Tipo de datos

text

If Other, please specify
Descripción

Language

Tipo de datos

text

4. Tobacco/Nicotine History
Descripción

If Yes, Complete information for ALL that are applicable

Tipo de datos

boolean

Cigarettes
Descripción

Tobacco/Nicotine History

Tipo de datos

boolean

Cigarettes: Frequency
Descripción

Tobacco/Nicotine History

Tipo de datos

text

Cigarettes: Start Date
Descripción

Tobacco/Nicotine History

Tipo de datos

date

Cigarettes: Continuing
Descripción

Tobacco/Nicotine History

Tipo de datos

boolean

Cigarettes: Stop Date
Descripción

Tobacco/Nicotine History

Tipo de datos

date

Cigars
Descripción

Tobacco/Nicotine History

Tipo de datos

boolean

Pipe
Descripción

Tobacco/Nicotine History

Tipo de datos

boolean

Chewing tobacco/snuff
Descripción

Tobacco/Nicotine History

Tipo de datos

boolean

Other
Descripción

Tobacco/Nicotine History

Tipo de datos

boolean

If Other, please specify
Descripción

Tobacco/Nicotine History

Tipo de datos

text

Cigars/Pipe/Chewing tobacco/snuff/Other: Frequency
Descripción

Tobacco/Nicotine History

Tipo de datos

text

Cigars/Pipe/Chewing tobacco/snuff/Other: Start Date
Descripción

Tobacco/Nicotine History

Tipo de datos

date

Cigars/Pipe/Chewing tobacco/snuff/Other: Continuing
Descripción

Tobacco/Nicotine History

Tipo de datos

boolean

Cigars/Pipe/Chewing tobacco/snuff/Other: Stop Date
Descripción

Tobacco/Nicotine History

Tipo de datos

date

5. Alcohol History
Descripción

If Yes, Complete information for ALL that are applicable.

Tipo de datos

boolean

Beer
Descripción

Alcohol History

Tipo de datos

boolean

Beer: Frequency
Descripción

Alcohol History

Tipo de datos

text

Beer: Start Date
Descripción

Alcohol History

Tipo de datos

date

Beer: Continuing
Descripción

Alcohol History

Tipo de datos

boolean

Beer: Stop Date
Descripción

Alcohol History

Tipo de datos

date

Wine
Descripción

Alcohol History

Tipo de datos

boolean

Wine: Frequency
Descripción

Alcohol History

Tipo de datos

text

Wine: Start Date
Descripción

Alcohol History

Tipo de datos

date

Wine: Continuing
Descripción

Alcohol History

Tipo de datos

boolean

Wine: Stop Date
Descripción

Alcohol History

Tipo de datos

date

Hard Liquor
Descripción

Alcohol History

Tipo de datos

boolean

Hard Liquor: Frequency
Descripción

Alcohol History

Tipo de datos

text

Hard Liquor: Start Date
Descripción

Alcohol History

Tipo de datos

date

Hard Liquor: Continuing
Descripción

Alcohol History

Tipo de datos

boolean

Hard Liquor: Stop Date
Descripción

Alcohol History

Tipo de datos

date

6. Illicit Substances History
Descripción

If Yes, Complete information for ALL that are applicable

Tipo de datos

boolean

Marijuana
Descripción

Illicit Substances History

Tipo de datos

boolean

Marijuana: Frequency
Descripción

Illicit Substances History

Tipo de datos

text

Marijuana: Start Date
Descripción

Illicit Substances History

Tipo de datos

date

Marijuana: Continuing
Descripción

Illicit Substances History

Tipo de datos

boolean

Marijuana: Stop Date
Descripción

Illicit Substances History

Tipo de datos

date

Cocaine
Descripción

Illicit Substances History

Tipo de datos

boolean

Cocaine: Frequency
Descripción

Illicit Substances History

Tipo de datos

text

Cocaine: Start Date
Descripción

Illicit Substances History

Tipo de datos

date

Cocaine: Continuing
Descripción

Illicit Substances History

Tipo de datos

boolean

Cocaine: Stop Date
Descripción

Illicit Substances History

Tipo de datos

date

Other (specify)
Descripción

Illicit Substances History

Tipo de datos

boolean

Other: Frequency
Descripción

Illicit Substances History

Tipo de datos

text

Other: Start Date
Descripción

Illicit Substances History

Tipo de datos

date

Other: Continuing
Descripción

Illicit Substances History

Tipo de datos

boolean

Other: Stop Date
Descripción

Illicit Substances History

Tipo de datos

date

If Other, please specify
Descripción

Illicit Substances History

Tipo de datos

text

Completed by (initials)
Descripción

Completed by (initials)

Tipo de datos

text

Date completed
Descripción

Date completed

Tipo de datos

date

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Similar models

Social History Form: UIC Quality Improvement CRF

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
Study Visit
Item
Study Visit
text
Item Group
Social History Form
Item
1. Highest Level of Education
text
1. Highest Level of Education
Code List
1. Highest Level of Education
CL Item
Grade school graduate (1)
CL Item
Some high school (2)
CL Item
High school graduate (3)
CL Item
Some collage (4)
CL Item
College graduate (5)
CL Item
Post college graduate (6)
2. Occupation
Item
2. Occupation
text
Item
Occupation
text
2. Occupation
Code List
Occupation
CL Item
Full Time  (1)
CL Item
Part-time (2)
CL Item
Retired___ (3)
CL Item
Unknown (4)
Occupation
Item
Occupation: If retired, please specify date
date
3a. Language
Item
3a. Language(s) in which subject is fluent: English
boolean
Language
Item
Language(s) in which subject is fluent: Spanish
boolean
Language
Item
Language(s) in which subject is fluent: Chinese
boolean
Language
Item
Language(s) in which subject is fluent: Tagalog
boolean
Language
Item
Language(s) in which subject is fluent: Korean
boolean
Language
Item
Language(s) in which subject is fluent: Russian
boolean
Language
Item
Language(s) in which subject is fluent: Polish
boolean
Language
Item
Language(s) in which subject is fluent: Other
boolean
Language
Item
If Other, please specify
text
Item
3b. Language in which subject requests study visits to be conducted
text
3b. Language in which subject requests study visits to be conducted
Code List
3b. Language in which subject requests study visits to be conducted
CL Item
English (1)
CL Item
Spanish (2)
CL Item
Chinese (3)
CL Item
Tagalog (4)
CL Item
Korean (5)
CL Item
Russian (6)
CL Item
Polish (7)
CL Item
Other (8)
Language
Item
If Other, please specify
text
4. Tobacco/Nicotine History
Item
4. Tobacco/Nicotine History
boolean
Tobacco/Nicotine History
Item
Cigarettes
boolean
Tobacco/Nicotine History
Item
Cigarettes: Frequency
text
Tobacco/Nicotine History
Item
Cigarettes: Start Date
date
Tobacco/Nicotine History
Item
Cigarettes: Continuing
boolean
Tobacco/Nicotine History
Item
Cigarettes: Stop Date
date
Tobacco/Nicotine History
Item
Cigars
boolean
Tobacco/Nicotine History
Item
Pipe
boolean
Tobacco/Nicotine History
Item
Chewing tobacco/snuff
boolean
Tobacco/Nicotine History
Item
Other
boolean
Tobacco/Nicotine History
Item
If Other, please specify
text
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Frequency
text
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Start Date
date
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Continuing
boolean
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Stop Date
date
5. Alcohol History
Item
5. Alcohol History
boolean
Alcohol History
Item
Beer
boolean
Alcohol History
Item
Beer: Frequency
text
Alcohol History
Item
Beer: Start Date
date
Alcohol History
Item
Beer: Continuing
boolean
Alcohol History
Item
Beer: Stop Date
date
Alcohol History
Item
Wine
boolean
Alcohol History
Item
Wine: Frequency
text
Alcohol History
Item
Wine: Start Date
date
Alcohol History
Item
Wine: Continuing
boolean
Alcohol History
Item
Wine: Stop Date
date
Alcohol History
Item
Hard Liquor
boolean
Alcohol History
Item
Hard Liquor: Frequency
text
Alcohol History
Item
Hard Liquor: Start Date
date
Alcohol History
Item
Hard Liquor: Continuing
boolean
Alcohol History
Item
Hard Liquor: Stop Date
date
6. Illicit Substances History
Item
6. Illicit Substances History
boolean
Illicit Substances History
Item
Marijuana
boolean
Illicit Substances History
Item
Marijuana: Frequency
text
Illicit Substances History
Item
Marijuana: Start Date
date
Illicit Substances History
Item
Marijuana: Continuing
boolean
Illicit Substances History
Item
Marijuana: Stop Date
date
Illicit Substances History
Item
Cocaine
boolean
Illicit Substances History
Item
Cocaine: Frequency
text
Illicit Substances History
Item
Cocaine: Start Date
date
Illicit Substances History
Item
Cocaine: Continuing
boolean
Illicit Substances History
Item
Cocaine: Stop Date
date
Illicit Substances History
Item
Other (specify)
boolean
Illicit Substances History
Item
Other: Frequency
text
Illicit Substances History
Item
Other: Start Date
date
Illicit Substances History
Item
Other: Continuing
boolean
Illicit Substances History
Item
Other: Stop Date
date
Illicit Substances History
Item
If Other, please specify
text
Completed by (initials)
Item
Completed by (initials)
text
Date completed
Item
Date completed
date
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