ID

18726

Beschrijving

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

Trefwoorden

Versies (2)
  1. 22-07-16 22-07-16 -
  2. 17-11-16 17-11-16 -
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17 november 2016

DOI

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Creative Commons BY-NC 3.0
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Demographics: CRF Wisconsin Madison

Engels

Demographics: CRF Wisconsin Madison

1 Formulieren  
Header
Beschrijving

Header

PI Name
Beschrijving

PI Name

Datatype

text

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

Protocol or IRB Number

Datatype

integer

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

Protocol Short Title

Datatype

text

Alias
UMLS CUI [1]
C2986303
Subject Initials
Beschrijving

Subject Initials

Datatype

text

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

Subject ID

Datatype

integer

Alias
UMLS CUI [1]
C2348585
Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Demographics
Beschrijving

Demographics

Subject UWHC Medical Record Number
Beschrijving

Subject UWHC Medical Record Number

Datatype

integer

Alias
UMLS CUI [1]
C1301894
First Name
Beschrijving

First Name

Datatype

text

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

Middle Name (or initial)

Datatype

text

Alias
UMLS CUI [1]
C2598119
Last Name
Beschrijving

Last Name

Datatype

text

Alias
UMLS CUI [1]
C1301584
Birthdate
Beschrijving

Birthdate

Datatype

date

Alias
UMLS CUI [1]
C0421451
Gender
Beschrijving

Gender

Datatype

text

Alias
UMLS CUI [1]
C0079399
Ethnicity
Beschrijving

Ethnicity

Datatype

text

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

Race

Datatype

boolean

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

Race

Datatype

boolean

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

Race

Datatype

boolean

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

Race

Datatype

boolean

Alias
UMLS CUI [1]
C3845561
White or Caucasian
Beschrijving

Race

Datatype

boolean

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

Race

Datatype

boolean

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

Other Medical Record Number(s)

Medical Record Number
Beschrijving

Medical Record Number

Datatype

integer

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

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

Datatype

text

Alias
UMLS CUI [1]
C0019994
Contact Information
Beschrijving

Contact Information

Address
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Unit number
Beschrijving

Unit number

Datatype

integer

Alias
UMLS CUI [1]
C0439148
City
Beschrijving

City

Datatype

text

Alias
UMLS CUI [1]
C0008848
State
Beschrijving

State

Datatype

text

Alias
UMLS CUI [1]
C1442792
Zip
Beschrijving

Zip

Datatype

integer

Alias
UMLS CUI [1]
C1521842
Phone number
Beschrijving

Phone number

Datatype

integer

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

Phone number

Datatype

text

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

Alternate Phone Number

Datatype

integer

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

Alternate Phone Number

Datatype

text

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

Email address

Datatype

text

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

Preferred method of contact

Datatype

text

Alias
UMLS CUI [1]
C1997600
Emergency contact
Beschrijving

Emergency contact

Name
Beschrijving

Name

Datatype

text

Alias
UMLS CUI [1]
C0027365
Address
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Unit number
Beschrijving

Unit number

Datatype

integer

Alias
UMLS CUI [1]
C0439148
City
Beschrijving

City

Datatype

text

Alias
UMLS CUI [1]
C0008848
State
Beschrijving

State

Datatype

text

Alias
UMLS CUI [1]
C1442792
Zip
Beschrijving

Zip

Datatype

integer

Alias
UMLS CUI [1]
C1521842
Phone Number
Beschrijving

Phone Number

Datatype

integer

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

Phone number

Datatype

text

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

Alternate Phone Number

Datatype

integer

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

Alternate Phone Number

Datatype

text

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

Email address

Datatype

text

Alias
UMLS CUI [1]
C1705961
Form completed By
Beschrijving

Form completed By

Datatype

text

Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
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Similar models

Demographics: CRF Wisconsin Madison

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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