ID

18744

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Drug Dispension & Accountability 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. 7/26/16 7/26/16 -
  2. 11/18/16 11/18/16 -
Uploaded on

November 18, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Drug Dispension & Accountability Log: CRF Wisconsin Madison

English

Drug Dispension & Accountability 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
Number of Pages
Description

Number of Pages

Data type

integer

Alias
UMLS CUI [1,1]
C1704732
UMLS CUI [1,2]
C0449788
Total Number of Pages
Description

Total Number of Pages

Data type

integer

Alias
UMLS CUI [1,1]
C1704732
UMLS CUI [1,2]
C0449788
Drug Dispensation & Accountability Log
Description

Drug Dispensation & Accountability Log

Subject Initials
Description

Subject Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Subject Study ID
Description

Subject Study ID

Data type

integer

Alias
UMLS CUI [1]
C2348585
Lot Number(s)
Description

Lot Number(s)

Data type

integer

Alias
UMLS CUI [1]
C1115660
Unit Dose (e.g. mg)
Description

Unit Dose

Data type

text

Alias
UMLS CUI [1]
C0869039
Drug Dispensation & Accountability Log: Dispensed to Subject
Description

Drug Dispensation & Accountability Log: Dispensed to Subject

Number of Containers Dispensed
Description

Number of Containers Dispensed

Data type

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0180098
UMLS CUI [1,3]
C0805077
Number of Units Dispensed
Description

Number of Units Dispensed

Data type

integer

Alias
UMLS CUI [1]
C0805077
Date Dispensed
Description

Date Dispensed

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0947323
Dispensed by (staff initials)
Description

Dispensed by (staff initials)

Data type

text

Alias
UMLS CUI [1,1]
C0947323
UMLS CUI [1,2]
C2986440
Drug Dispensation & Accountability Log: Returned by Subject
Description

Drug Dispensation & Accountability Log: Returned by Subject

Number of Containers Returned
Description

Number of Containers Returned

Data type

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0180098
UMLS CUI [1,3]
C0332156
Number of units returned
Description

Number of units returned

Data type

integer

Alias
UMLS CUI [1]
C2981651
Date Returned
Description

Date Returned

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0332156
Verified by (staff initials)
Description

Verified by (staff initials)

Data type

text

Alias
UMLS CUI [1,1]
C1547321
UMLS CUI [1,2]
C2986440
Drug Dispensation & Accountability Log: Compliance
Description

Drug Dispensation & Accountability Log: Compliance

Expected number of units to be used/taken
Description

Expected number of units to be used/taken

Data type

integer

Alias
UMLS CUI [1,1]
C0449961
UMLS CUI [1,2]
C1517001
Actual number of units used/taken
Description

Actual number of units used/taken

Data type

integer

Alias
UMLS CUI [1,1]
C0449961
UMLS CUI [1,2]
C0237400
% compliance
Description

% compliance

Data type

integer

Alias
UMLS CUI [1]
C3714738
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Similar models

Drug Dispension & Accountability 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])
Number of Pages
Item
Number of Pages
integer
C1704732 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Total Number of Pages
Item
Total Number of Pages
integer
C1704732 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Item Group
Drug Dispensation & Accountability Log
Subject Initials
Item
Subject Initials
text
C2986440 (UMLS CUI [1])
Subject Study ID
Item
Subject Study ID
integer
C2348585 (UMLS CUI [1])
Lot Number(s)
Item
Lot Number(s)
integer
C1115660 (UMLS CUI [1])
Unit Dose
Item
Unit Dose (e.g. mg)
text
C0869039 (UMLS CUI [1])
Item Group
Drug Dispensation & Accountability Log: Dispensed to Subject
Number of Containers Dispensed
Item
Number of Containers Dispensed
integer
C0449788 (UMLS CUI [1,1])
C0180098 (UMLS CUI [1,2])
C0805077 (UMLS CUI [1,3])
Number of Units Dispensed
Item
Number of Units Dispensed
integer
C0805077 (UMLS CUI [1])
Date Dispensed
Item
Date Dispensed
date
C0011008 (UMLS CUI [1,1])
C0947323 (UMLS CUI [1,2])
Dispensed by (staff initials)
Item
Dispensed by (staff initials)
text
C0947323 (UMLS CUI [1,1])
C2986440 (UMLS CUI [1,2])
Item Group
Drug Dispensation & Accountability Log: Returned by Subject
Number of Containers Returned
Item
Number of Containers Returned
integer
C0449788 (UMLS CUI [1,1])
C0180098 (UMLS CUI [1,2])
C0332156 (UMLS CUI [1,3])
Number of units returned
Item
Number of units returned
integer
C2981651 (UMLS CUI [1])
Date Returned
Item
Date Returned
date
C0011008 (UMLS CUI [1,1])
C0332156 (UMLS CUI [1,2])
Verified by (staff initials)
Item
Verified by (staff initials)
text
C1547321 (UMLS CUI [1,1])
C2986440 (UMLS CUI [1,2])
Item Group
Drug Dispensation & Accountability Log: Compliance
Expected number of units to be used/taken
Item
Expected number of units to be used/taken
integer
C0449961 (UMLS CUI [1,1])
C1517001 (UMLS CUI [1,2])
Actual number of units used/taken
Item
Actual number of units used/taken
integer
C0449961 (UMLS CUI [1,1])
C0237400 (UMLS CUI [1,2])
% compliance
Item
% compliance
integer
C3714738 (UMLS CUI [1])
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