ID

18733

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Concomitant Medication Log. 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. 7/23/16 7/23/16 -
  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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Concomitant Medication Log: CRF Wisconsin Madison

English

Concomitant Medication Log: CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Alias
UMLS CUI [1,1]
C0027365
UMLS CUI [1,2]
C1521895
Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Alias
UMLS CUI [1]
C2348563
Protocol Short Title
Description

Protocol Short Title

Data type

text

Alias
UMLS CUI [1,1]
C2348563
UMLS CUI [1,2]
C1705824
Subject Initials
Description

Subject Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Subject ID
Description

Subject ID

Data type

integer

Alias
UMLS CUI [1]
C2348585
Number of Page
Description

Number of Page

Data type

integer

Alias
UMLS CUI [1,1]
C1704732
UMLS CUI [1,2]
C0449788
Total amount of pages
Description

Total amount of pages

Data type

integer

Alias
UMLS CUI [1,1]
C1704732
UMLS CUI [1,2]
C0449788
Concomitant Medication Log
Description

Concomitant Medication Log

#
Description

#

Data type

integer

Medication/ Non-drug Therapy
Description

Medication/ Non-drug Therapy

Data type

text

Alias
UMLS CUI [1]
C0013227
UMLS CUI [2]
C0087111
Indication
Description

Indication

Data type

text

Alias
UMLS CUI [1]
C3146298
Dose (per admin)
Description

Medication Dose

Data type

float

Alias
UMLS CUI [1]
C3174092
Dose Units
Description

1= g 2= mg 3= ug 4= L 5= mL 6= IU 7= Other

Data type

text

Alias
UMLS CUI [1,1]
C0178602
UMLS CUI [1,2]
C1519795
Schedule/Frequency
Description

1= QD (once a day) 2= BID (twice a day) 3= TID (three times a day) 4= QID (four times a day) 5= QOD (every other day) 6= QM (every month) 7= QOM (every other month) 8= QH (every hour) 9= AC (before meals) 10= PC (after meals) 11= PRN (as needed) 12= Other

Data type

text

Alias
UMLS CUI [1]
C0013154
UMLS CUI [2]
C0439603
Dose Form
Description

1= Tablet 2= Capsule 3= Ointment 4=Suppository 5=Aerosol 6=Spray 7=Suspension 8= Patch 9=Gas 10=Gel 11=Cream 12=Powder

Data type

text

Alias
UMLS CUI [1]
C0013058
Route of Administration
Description

1= Oral 2= Topical 3= Subcutaneous 4= Intradermal 5= Transdermal 6= Intraocular 7= Intramuscular 8= Inhalation 9= Intravenous 10= Intraperitoneal 11= Nasal 12= Vaginal 13= Rectal 14= Other

Data type

text

Alias
UMLS CUI [1]
C3469597
Start Date
Description

Start Date

Data type

date

Alias
UMLS CUI [1]
C0808070
End Date
Description

End Date

Data type

date

Alias
UMLS CUI [1]
C0806020
Baseline Med
Description

Baseline Med

Data type

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C1442488
Continuing at end of study
Description

Continuing at end of study

Data type

boolean

Alias
UMLS CUI [1]
C1553904
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Similar models

Concomitant Medication Log: 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 [1,1])
C1521895 (UMLS CUI [1,2])
Protocol or IRB Number
Item
Protocol or IRB Number
integer
C2348563 (UMLS CUI [1])
Protocol Short Title
Item
Protocol Short Title
text
C2348563 (UMLS CUI [1,1])
C1705824 (UMLS CUI [1,2])
Subject Initials
Item
Subject Initials
text
C2986440 (UMLS CUI [1])
Subject ID
Item
Subject ID
integer
C2348585 (UMLS CUI [1])
Number of Page
Item
Number of Page
integer
C1704732 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Total amount of pages
Item
Total amount of pages
integer
C1704732 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Item Group
Concomitant Medication Log
#
Item
#
integer
Medication/ Non-drug Therapy
Item
Medication/ Non-drug Therapy
text
C0013227 (UMLS CUI [1])
C0087111 (UMLS CUI [2])
Indication
Item
Indication
text
C3146298 (UMLS CUI [1])
Medication Dose
Item
Dose (per admin)
float
C3174092 (UMLS CUI [1])
Dose Units
Item
Dose Units
text
C0178602 (UMLS CUI [1,1])
C1519795 (UMLS CUI [1,2])
Schedule/Frequency
Item
Schedule/Frequency
text
C0013154 (UMLS CUI [1])
C0439603 (UMLS CUI [2])
Dose Form
Item
Dose Form
text
C0013058 (UMLS CUI [1])
Route of Administration
Item
Route of Administration
text
C3469597 (UMLS CUI [1])
Start Date
Item
Start Date
date
C0808070 (UMLS CUI [1])
End Date
Item
End Date
date
C0806020 (UMLS CUI [1])
Baseline Med
Item
Baseline Med
boolean
C0013227 (UMLS CUI [1,1])
C1442488 (UMLS CUI [1,2])
Continuing at end of study
Item
Continuing at end of study
boolean
C1553904 (UMLS CUI [1])
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