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HLA-B*5701 And Hypersensitivity To Abacavir Inform Screening NCT00373945

1 Formulär  
Inform Screening
Beskrivning

Inform Screening

Alias
UMLS CUI-1
C1710477
Subject initials
Beskrivning

Subject initials

Datatyp

text

Alias
UMLS CUI [1]
C2986440
Date of birth
Beskrivning

Date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
What is the primary method that prompted the subject's interest in the study?
Beskrivning

interest in the study

Datatyp

integer

Alias
UMLS CUI [1,1]
C0008976
UMLS CUI [1,2]
C0543488
UMLS CUI [1,3]
C0392360
Was this subject a screen failure?
Beskrivning

screen failure

Datatyp

text

Alias
UMLS CUI [1]
C1710476
Was this subject a screen failure? Yes, select primary reason:
Beskrivning

primary reason for screen failure

Datatyp

integer

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C0392360
primary reason for screen failure
Beskrivning

If other, please specify

Datatyp

text

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C0392360
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Similar models

HLA-B*5701 And Hypersensitivity To Abacavir Inform Screening NCT00373945

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Inform Screening
C1710477 (UMLS CUI-1)
Subject initials
Item
Subject initials
text
C2986440 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
What is the primary method that prompted the subject's interest in the study?
integer
C0008976 (UMLS CUI [1,1])
C0543488 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
interest in the study
Code List
What is the primary method that prompted the subject's interest in the study?
CL Item
Clinic patient (site actively reviews patient charts and/or databases and initiates contact with patient). (1)
CL Item
Physician referral (e.g., lunch-n-learn, letter to colleagues, etc.) (2)
CL Item
Referred by family member (3)
CL Item
Referred by study participant (4)
CL Item
Subject-initiated internet search (e.g. discovered findclinicalstudy.com) (5)
CL Item
Other internet provider paid by GSK (e.g., harrisinteractive.com), specify (6)
CL Item
Information in clinic (e.g., posters, brochure, etc.) (7)
CL Item
Community outreach (e.g., healthfair, advocacy groups, support groups, etc.) (8)
CL Item
Call center (16)
CL Item
Other, specify (OT)
Item
Was this subject a screen failure?
text
C1710476 (UMLS CUI [1])
screen failure
Code List
Was this subject a screen failure?
CL Item
No (N)
CL Item
Yes (Y)
Item
Was this subject a screen failure? Yes, select primary reason:
integer
C1710476 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
primary reason for screen failure
Code List
Was this subject a screen failure? Yes, select primary reason:
CL Item
Protocol violation (3)
CL Item
Subject decided to withdraw from the study (4)
CL Item
Non-compliance (8)
CL Item
Other, specify (OT)
primary reason for screen failure
Item
primary reason for screen failure
text
C1710476 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
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