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Demographics: CRF QMCR University of Alberta

1 Formulär  
General Information
Beskrivning

General Information

Study Name
Beskrivning

Study Name

Datatyp

text

Site Number
Beskrivning

Site Number

Datatyp

integer

Pt_ID
Beskrivning

Pt_ID

Datatyp

integer

Visit Date
Beskrivning

Visit Date

Datatyp

date

Visit Type
Beskrivning

Visit Type

Datatyp

text

Demographics
Beskrivning

Demographics

1. Gender
Beskrivning

1. Gender

Datatyp

text

2. Date of Birth
Beskrivning

2. Date of Birth

Datatyp

date

3. Race (See Description)
Beskrivning

Choose only one with which you most closely identify

Datatyp

text

4. Ethnicity (See Description)
Beskrivning

Choose only one with which you most closely identify

Datatyp

text

Date Informed Consent Signed
Beskrivning

Date Informed Consent Signed

Datatyp

date

Investigator Signature
Beskrivning

Investigator Signature

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

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Similar models

Demographics: CRF QMCR University of Alberta

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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