Informatie:
Fout:
ID
16963
Beschrijving
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
Trefwoorden
Versies (1)
- 17-08-16 17-08-16 -
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17 augustus 2016
DOI
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Licentie
Creative Commons BY-NC 3.0
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Social History Form: UIC Quality Improvement CRF
Social History Form: UIC Quality Improvement CRF
- StudyEvent: ODM
Similar models
Social History 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
Study Visit
Item
Study Visit
text
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
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
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