Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Sex
text
C0079399 (UMLS CUI [1])
Item
Ethnicity
integer
C0015031 (UMLS CUI [1])
CL Item
Hispanic or Latino (1)
CL Item
Not Hispanic or Latino (2)
Item
Self-reported Race
integer
C0034510 (UMLS CUI [1])
Code List
Self-reported Race
Item
Geographic Ancestry
integer
C3841890 (UMLS CUI [1,1])
C0034510 (UMLS CUI [1,2])
Code List
Geographic Ancestry
CL Item
African American/African Heritage (11)
CL Item
American Indian or Alaskan Native (12)
CL Item
Asian - Central/South Asian Heritage (13)
CL Item
Asian - East Asian Heritage (14)
CL Item
Asian - Japanese Heritage (15)
CL Item
Asian - South East Asian Heritage (16)
CL Item
Native Hawaiian or Other Pacific Islander (17)
CL Item
White - Arabic/North African Heritage (18)
CL Item
White - White/Caucasian/European Heritage (19)
Item
Has informed consent been obtained for PGx-Pharmacogenetic Research?
text
C0021430 (UMLS CUI [1])
Code List
Has informed consent been obtained for PGx-Pharmacogenetic Research?
date of informed consent
Item
Date informed consent obtained for PGx-Pharmacogenetic Research:
date
C0011008 (UMLS CUI [1,1])
C0021430 (UMLS CUI [1,2])
Item
Has blood sample been collected for PGx-Pharmacogenetic Research?
text
C0005834 (UMLS CUI [1])
Code List
Has blood sample been collected for PGx-Pharmacogenetic Research?
date sample taken
Item
Record date sample taken
date
C0011008 (UMLS CUI [1,1])
C0005834 (UMLS CUI [1,2])
Item
No, provide reason below
integer
C0021430 (UMLS CUI [1,1])
C1705116 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Code List
No, provide reason below
CL Item
Subject declined (1)
CL Item
Subject not asked by Investigator (2)
CL Item
Other, specify (Z)
reason informed consent was not obtained
Item
reason informed consent was not obtained
text
C0021430 (UMLS CUI [1,1])
C1705116 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Sample type
Item
Sample type
text
C2347029 (UMLS CUI [1])
Genetics Type
Item
Genetics Type
text
C0017399 (UMLS CUI [1])
Item
Did the subject meet all the entry criteria?
text
C1516637 (UMLS CUI [1])
Code List
Did the subject meet all the entry criteria?
Item
Please select all boxes corresponding to violations of any inclusion/exclusion criteria
text
C1516637 (UMLS CUI [1])
Code List
Please select all boxes corresponding to violations of any inclusion/exclusion criteria
CL Item
Inclusion Criteria 1 (I01)
CL Item
Inclusion Criteria 2 (I02)
CL Item
Inclusion Criteria 3 (I03)
CL Item
Inclusion Criteria 4 (I04)
CL Item
Inclusion Criteria 5 (I05)
CL Item
Exclusion Criteria 1 (E01)
CL Item
Exclusion Criteria 2 (E02)
CL Item
Exclusion Criteria 3 (E03)
exception
Item
Please clarify exception(s) below
text
C1516637 (UMLS CUI [1])
Item
Are there any risk factors or is the mode of transmission known that could have resulted in this subject acquiring HIV?
text
C0035648 (UMLS CUI [1,1])
C1443844 (UMLS CUI [1,2])
Code List
Are there any risk factors or is the mode of transmission known that could have resulted in this subject acquiring HIV?
Item
Yes, tick all that apply
integer
C0035648 (UMLS CUI [1,1])
C1443844 (UMLS CUI [1,2])
Code List
Yes, tick all that apply
CL Item
Homosexual contact (1)
CL Item
Heterosexual contact (2)
CL Item
Injectable drug use (3)
CL Item
Hemophilia-associated injections (5)
CL Item
Occupational exposure (6)
CL Item
Other, specify (OT)
risk factors / transmission of HIV
Item
risk factors / transmission of HIV
text
C0035648 (UMLS CUI [1,1])
C1443844 (UMLS CUI [1,2])
Date of visit
Item
Date of visit
date
C1320303 (UMLS CUI [1,1])
C0185125 (UMLS CUI [1,2])
Item
Has the subject undergone tanning (artificial or natural UV rays) in the past 14 days?
text
C0302595 (UMLS CUI [1])
Code List
Has the subject undergone tanning (artificial or natural UV rays) in the past 14 days?
time of application
Item
At what time were the two patches applied to the prepared area of the subject's back (or upper arm, if applicable)?
time
C0040223 (UMLS CUI [1,1])
C0185125 (UMLS CUI [1,2])
C0030646 (UMLS CUI [1,3])