ID

18726

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Demographics. Case Report Form (CRF)/Source Document templates were created for University of Wisconsin-Madison researchers. These templates are consistent with the FDA's CDASH (Clinical Data Acquisition Standards Harmonization) standards. The CDASH standards identify those elements that should be captured on a Case Report Form (CRF). The forms serve only as templates, and must be edited to meet the study data collection needs as described in the protocol.

Link

https://ictr.wisc.edu/CaseReptTempt

Keywords

Versions (2)
  1. 7/22/16 7/22/16 -
  2. 11/17/16 11/17/16 -
Uploaded on

November 17, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Demographics: CRF Wisconsin Madison

English

Demographics: CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Alias
UMLS CUI [1,1]
C0008971
UMLS CUI [1,2]
C0600091
Protocol Short Title
Description

Protocol Short Title

Data type

text

Alias
UMLS CUI [1]
C2986303
Subject Initials
Description

Subject Initials

Data type

text

Alias
UMLS CUI [1,1]
C0681850
UMLS CUI [1,2]
C1555582
Subject ID
Description

Subject ID

Data type

integer

Alias
UMLS CUI [1]
C2348585
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Demographics
Description

Demographics

Subject UWHC Medical Record Number
Description

Subject UWHC Medical Record Number

Data type

integer

Alias
UMLS CUI [1]
C1301894
First Name
Description

First Name

Data type

text

Alias
UMLS CUI [1]
C1443235
Middle Name (or initial)
Description

Middle Name (or initial)

Data type

text

Alias
UMLS CUI [1]
C2598119
Last Name
Description

Last Name

Data type

text

Alias
UMLS CUI [1]
C1301584
Birthdate
Description

Birthdate

Data type

date

Alias
UMLS CUI [1]
C0421451
Gender
Description

Gender

Data type

text

Alias
UMLS CUI [1]
C0079399
Ethnicity
Description

Ethnicity

Data type

text

Alias
UMLS CUI [1]
C0015031
American Indian or Alaska Native
Description

Race

Data type

boolean

Alias
UMLS CUI [1,1]
C0002460
UMLS CUI [1,2]
C0682125
Asian
Description

Race

Data type

boolean

Alias
UMLS CUI [1]
C0078988
Black or African American
Description

Race

Data type

boolean

Alias
UMLS CUI [1]
C0085756
Native Hawaiian or Other Pacific Islander
Description

Race

Data type

boolean

Alias
UMLS CUI [1]
C3845561
White or Caucasian
Description

Race

Data type

boolean

Alias
UMLS CUI [1]
C0043157
Unknown or not Reported
Description

Race

Data type

boolean

Alias
UMLS CUI [1]
C0439673
Other Medical Record Number(s)
Description

Other Medical Record Number(s)

Medical Record Number
Description

Medical Record Number

Data type

integer

Alias
UMLS CUI [1]
C1301894
Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
Description

Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)

Data type

text

Alias
UMLS CUI [1]
C0019994
Contact Information
Description

Contact Information

Address
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Unit number
Description

Unit number

Data type

integer

Alias
UMLS CUI [1]
C0439148
City
Description

City

Data type

text

Alias
UMLS CUI [1]
C0008848
State
Description

State

Data type

text

Alias
UMLS CUI [1]
C1442792
Zip
Description

Zip

Data type

integer

Alias
UMLS CUI [1]
C1521842
Phone number
Description

Phone number

Data type

integer

Alias
UMLS CUI [1]
C1515258
What kind of phone number is it?
Description

Phone number

Data type

text

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C0332307
Alternate Phone Number
Description

Alternate Phone Number

Data type

integer

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C1523987
What kind of Phone number is it?
Description

Alternate Phone Number

Data type

text

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C0332307
Email address
Description

Email address

Data type

text

Alias
UMLS CUI [1]
C1705961
Preferred method of contact
Description

Preferred method of contact

Data type

text

Alias
UMLS CUI [1]
C1997600
Emergency contact
Description

Emergency contact

Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Address
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Unit number
Description

Unit number

Data type

integer

Alias
UMLS CUI [1]
C0439148
City
Description

City

Data type

text

Alias
UMLS CUI [1]
C0008848
State
Description

State

Data type

text

Alias
UMLS CUI [1]
C1442792
Zip
Description

Zip

Data type

integer

Alias
UMLS CUI [1]
C1521842
Phone Number
Description

Phone Number

Data type

integer

Alias
UMLS CUI [1]
C1515258
What kind of phone number is it?
Description

Phone number

Data type

text

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C0332307
Alternate Phone Number
Description

Alternate Phone Number

Data type

integer

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C1523987
What kind of phone number is it?
Description

Alternate Phone Number

Data type

text

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C0332307
Email address
Description

Email address

Data type

text

Alias
UMLS CUI [1]
C1705961
Form completed By
Description

Form completed By

Data type

text

Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
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Similar models

Demographics: CRF Wisconsin Madison

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
PI Name
Item
PI Name
text
C0027365 (UMLS CUI [1])
Protocol or IRB Number
Item
Protocol or IRB Number
integer
C0008971 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Protocol Short Title
Item
Protocol Short Title
text
C2986303 (UMLS CUI [1])
Subject Initials
Item
Subject Initials
text
C0681850 (UMLS CUI [1,1])
C1555582 (UMLS CUI [1,2])
Subject ID
Item
Subject ID
integer
C2348585 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Item Group
Demographics
Subject UWHC Medical Record Number
Item
Subject UWHC Medical Record Number
integer
C1301894 (UMLS CUI [1])
First Name
Item
First Name
text
C1443235 (UMLS CUI [1])
Middle Name (or initial)
Item
Middle Name (or initial)
text
C2598119 (UMLS CUI [1])
Last Name
Item
Last Name
text
C1301584 (UMLS CUI [1])
Birthdate
Item
Birthdate
date
C0421451 (UMLS CUI [1])
Item
Gender
text
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
Male (1)
CL Item
Female (2)
CL Item
Unknown or not Reported (3)
Item
Ethnicity
text
C0015031 (UMLS CUI [1])
Ethnicity
Code List
Ethnicity
CL Item
Hispanic (1)
CL Item
Non-Hispanic (2)
CL Item
Unknown or not Reported (3)
Race
Item
American Indian or Alaska Native
boolean
C0002460 (UMLS CUI [1,1])
C0682125 (UMLS CUI [1,2])
Race
Item
Asian
boolean
C0078988 (UMLS CUI [1])
Race
Item
Black or African American
boolean
C0085756 (UMLS CUI [1])
Race
Item
Native Hawaiian or Other Pacific Islander
boolean
C3845561 (UMLS CUI [1])
Race
Item
White or Caucasian
boolean
C0043157 (UMLS CUI [1])
Race
Item
Unknown or not Reported
boolean
C0439673 (UMLS CUI [1])
Item Group
Other Medical Record Number(s)
Medical Record Number
Item
integer
C1301894 (UMLS CUI [1])
Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
Item
Hospital/Care Provider (e.g VA Hospital, Meriter Hospital, EPIC)
text
C0019994 (UMLS CUI [1])
Item Group
Contact Information
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Unit number
Item
Unit number
integer
C0439148 (UMLS CUI [1])
City
Item
City
text
C0008848 (UMLS CUI [1])
State
Item
State
text
C1442792 (UMLS CUI [1])
Zip
Item
Zip
integer
C1521842 (UMLS CUI [1])
Phone number
Item
Phone number
integer
C1515258 (UMLS CUI [1])
Item
What kind of phone number is it?
text
C1515258 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Phone number
Code List
What kind of phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Alternate Phone Number
Item
Alternate Phone Number
integer
C1515258 (UMLS CUI [1,1])
C1523987 (UMLS CUI [1,2])
Item
What kind of Phone number is it?
text
C1515258 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Alternate Phone Number
Code List
What kind of Phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Email address
Item
Email address
text
C1705961 (UMLS CUI [1])
Preferred method of contact
Item
Preferred method of contact
text
C1997600 (UMLS CUI [1])
Item Group
Emergency contact
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Unit number
Item
integer
C0439148 (UMLS CUI [1])
City
Item
City
text
C0008848 (UMLS CUI [1])
State
Item
State
text
C1442792 (UMLS CUI [1])
Zip
Item
Zip
integer
C1521842 (UMLS CUI [1])
Phone Number
Item
Phone Number
integer
C1515258 (UMLS CUI [1])
Item
What kind of phone number is it?
text
C1515258 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Phone number
Code List
What kind of phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Alternate Phone Number
Item
Alternate Phone Number
integer
C1515258 (UMLS CUI [1,1])
C1523987 (UMLS CUI [1,2])
Item
What kind of phone number is it?
text
C1515258 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Alternate Phone Number
Code List
What kind of phone number is it?
CL Item
Home (1)
CL Item
Cell (2)
CL Item
Work (3)
CL Item
Other (4)
Email address
Item
Email address
text
C1705961 (UMLS CUI [1])
Form completed By
Item
Form completed By
text
Date
Item
Date
date
C0011008 (UMLS CUI [1])
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