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Demographics: CRF QMCR University of Alberta

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General Information
Beschrijving

General Information

Study Name
Beschrijving

Study Name

Datatype

text

Site Number
Beschrijving

Site Number

Datatype

integer

Pt_ID
Beschrijving

Pt_ID

Datatype

integer

Visit Date
Beschrijving

Visit Date

Datatype

date

Visit Type
Beschrijving

Visit Type

Datatype

text

Demographics
Beschrijving

Demographics

1. Gender
Beschrijving

1. Gender

Datatype

text

2. Date of Birth
Beschrijving

2. Date of Birth

Datatype

date

3. Race (See Description)
Beschrijving

Choose only one with which you most closely identify

Datatype

text

4. Ethnicity (See Description)
Beschrijving

Choose only one with which you most closely identify

Datatype

text

Date Informed Consent Signed
Beschrijving

Date Informed Consent Signed

Datatype

date

Investigator Signature
Beschrijving

Investigator Signature

Datatype

text

Date
Beschrijving

Date

Datatype

date

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Similar models

Demographics: CRF QMCR University of Alberta

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
General Information
Study Name
Item
Study Name
text
Site Number
Item
Site Number
integer
Pt_ID
Item
Pt_ID
integer
Visit Date
Item
Visit Date
date
Item
Visit Type
text
Visit Type
Code List
Visit Type
CL Item
Screening (1)
CL Item
Baseline (2)
Item Group
Demographics
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 (See Description)
text
3. Race (See Description)
Code List
3. Race (See Description)
CL Item
American Indian or Alaska Native (1)
CL Item
Asian (2)
CL Item
Black or African-American (3)
CL Item
Native Hawaiian or Pacific Islander (4)
CL Item
White (5)
CL Item
More than one race (6)
CL Item
Unknown or not reported (7)
Item
4. Ethnicity (See Description)
text
4. Ethnicity (See Description)
Code List
4. Ethnicity (See Description)
CL Item
Hispanic or Latino (1)
CL Item
Not Hispanic or Latino (2)
CL Item
Unknown or not reported (3)
Date Informed Consent Signed
Item
Date Informed Consent Signed
date
Investigator Signature
Item
Investigator Signature
text
Date
Item
Date
date
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