ID

23892

Beschreibung

Study part: Vacccine Administration Booster Dose. A phase 2 study to assess safety, reactogenicity and immunogenicity of a booster dose of an investigational vaccination regimen and GSK Biologicals Hib-MenC vaccine (co-administered with Infanrix penta) compared to a booster dose of Menjugate (co-administered with Infanrix hexa).Patient Level Data: Study Listed on ClinicalStudyDataRequest.com. Study ID: 100381, Clinical Study ID: 100381

Stichworte

Versionen (1)
  1. 16.07.17 16.07.17 -
Rechteinhaber

GlaxoSmithKline

Hochgeladen am

16. Juli 2017

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Vacccine Administration Booster Dose Hib-MenCY-TT-004 BST 003 Neisseria Meningitidis-Haemophilus influenzae type b Vaccine 100381

Englisch

Vacccine Administration Booster Dose

1 Formulare  
Vaccine Administration Group Hib-MenCY or Hib-MenC
Beschreibung

Vaccine Administration Group Hib-MenCY or Hib-MenC

Alias
UMLS CUI-1
C2368628
Subject number
Beschreibung

Subject number

Datentyp

integer

Alias
UMLS CUI [1]
C2348585
Please complete only if different from visit date :
Beschreibung

date vaccine administration

Datentyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2368628
Vaccine administration Hib-MenCY Vaccine
Beschreibung

Side / site route: Left Thigh I.M.

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C2352428
If Replacement vial, comment
Beschreibung

comment

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Has the study vaccine been administered according to the Protocol ?
Beschreibung

vaccine administration site route side

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1515974
UMLS CUI [1,3]
C0013153
UMLS CUI [1,4]
C0441987
Vaccine administration DTPa-HBV-IPV Vaccine
Beschreibung

Side / site route: Right Thigh I.M.

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1121707
If Replacement vial, comment
Beschreibung

comment

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Has the study vaccine been administered according to the Protocol ?
Beschreibung

vaccine administration site route side

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1515974
UMLS CUI [1,3]
C0013153
UMLS CUI [1,4]
C0441987
Vaccine Administration Group Control
Beschreibung

Vaccine Administration Group Control

Alias
UMLS CUI-1
C2368628
UMLS CUI-2
C0009932
Subject number
Beschreibung

Subject number

Datentyp

integer

Alias
UMLS CUI [1]
C2348585
Please complete only if different from visit date :
Beschreibung

date vaccine administration

Datentyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2368628
Vaccine administration MenC Vaccine
Beschreibung

Side / site route: Left Thigh I.M.

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1720015
If Replacement vial, comment
Beschreibung

comment

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Has the study vaccine been administered according to the Protocol ?
Beschreibung

vaccine administration site route side

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1515974
UMLS CUI [1,3]
C0013153
UMLS CUI [1,4]
C0441987
Vaccine administration DTPa-HBV-IPV/Hib Vaccine
Beschreibung

Side / site route: Right Thigh I.M.

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1121707
If Replacement vial, comment
Beschreibung

comment

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Has the study vaccine been administered according to the Protocol ?
Beschreibung

vaccine administration site route side

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1515974
UMLS CUI [1,3]
C0013153
UMLS CUI [1,4]
C0441987
Why not administered ?
Beschreibung

Why not administered ?

Alias
UMLS CUI-1
C2368628
UMLS CUI-2
C0205544
Why not administered ?
Beschreibung

Vaccine administration cancelled

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C0205544
If SAE, Please specify SAE N° :
Beschreibung

SAE

Datentyp

text

Alias
UMLS CUI [1]
C1519255
If AEX, Please specify AE N° (Unsolicited) or code (Solicited) : :
Beschreibung

non serious adverse event

Datentyp

text

Alias
UMLS CUI [1]
C1518404
If other, please specify
Beschreibung

(e.g. : consent withdrawal, Protocol violation, …)

Datentyp

text

Alias
UMLS CUI [1]
C0205394
Please tick who took the decision :
Beschreibung

person Vaccine administration cancelled

Datentyp

text

Alias
UMLS CUI [1]
C0027361
Zum Seitenanfang zurückkehren

Ähnliche Modelle

Vacccine Administration Booster Dose

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Vaccine Administration Group Hib-MenCY or Hib-MenC
C2368628 (UMLS CUI-1)
Subject number
Item
Subject number
integer
C2348585 (UMLS CUI [1])
date vaccine administration
Item
Please complete only if different from visit date :
date
C0011008 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
Item
Vaccine administration Hib-MenCY Vaccine
text
C2368628 (UMLS CUI [1,1])
C2352428 (UMLS CUI [1,2])
vaccine administration
Code List
Vaccine administration Hib-MenCY Vaccine
CL Item
Hib-MenCY Vaccine OR Hib-MenC Vaccine (Hib-MenCY Vaccine OR Hib-MenC Vaccine)
CL Item
Replacement vial (Replacement vial)
CL Item
Wrong vial number (Wrong vial number)
CL Item
Not administered (Not administered)
comment
Item
If Replacement vial, comment
text
C0947611 (UMLS CUI [1])
Item
Has the study vaccine been administered according to the Protocol ?
text
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
C0013153 (UMLS CUI [1,3])
C0441987 (UMLS CUI [1,4])
vaccine administration site route side
Code List
Has the study vaccine been administered according to the Protocol ?
CL Item
Yes (1)
CL Item
No, Side: Left, Site: Deltoid, Route: I.M (2)
CL Item
No, Side: Left, Site: Deltoid, Route: S.C (3)
CL Item
No, Side: Right, Site: Deltoid, Route: I.M (4)
CL Item
No, Side: Right, Site: Deltoid, Route: S.C (5)
CL Item
No, Side: Left, Site: Thigh, Route: I:M (6)
CL Item
No, Side: Left, Site: Thigh, Route: S.C (7)
CL Item
No, Side: Right, Site: Thigh, Route: I.M (8)
CL Item
No, Side: Right, Site: Thigh, Route: S.C (9)
CL Item
No, Side: Left, Site: Buttock, Route: I.M (10)
CL Item
No, Side: Left, Site: Buttock, Route: S.C (11)
CL Item
No, Side: Right, Site: Buttock, Route: I.M (12)
CL Item
No, Side: Right, Site: Buttock, Route: S.C (13)
Item
Vaccine administration DTPa-HBV-IPV Vaccine
text
C2368628 (UMLS CUI [1,1])
C1121707 (UMLS CUI [1,2])
vaccine administration DTPa-HBV-IPV Vaccine
Code List
Vaccine administration DTPa-HBV-IPV Vaccine
CL Item
DTPa-HBV-IPV Vaccine (DTPa-HBV-IPV Vaccine)
CL Item
Replacement vial (Replacement vial)
CL Item
Wrong vial number (Wrong vial number)
CL Item
Not administered (Not administered)
comment
Item
If Replacement vial, comment
text
C0947611 (UMLS CUI [1])
Item
Has the study vaccine been administered according to the Protocol ?
text
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
C0013153 (UMLS CUI [1,3])
C0441987 (UMLS CUI [1,4])
vaccine administration site route side
Code List
Has the study vaccine been administered according to the Protocol ?
CL Item
Yes (1)
CL Item
No, Side: Left, Site: Deltoid, Route: I.M (2)
CL Item
No, Side: Left, Site: Deltoid, Route: S.C (3)
CL Item
No, Side: Right, Site: Deltoid, Route: I.M (4)
CL Item
No, Side: Right, Site: Deltoid, Route: S.C (5)
CL Item
No, Side: Left, Site: Thigh, Route: I:M (6)
CL Item
No, Side: Left, Site: Thigh, Route: S.C (7)
CL Item
No, Side: Right, Site: Thigh, Route: I.M (8)
CL Item
No, Side: Right, Site: Thigh, Route: S.C (9)
CL Item
No, Side: Left, Site: Buttock, Route: I.M (10)
CL Item
No, Side: Left, Site: Buttock, Route: S.C (11)
CL Item
No, Side: Right, Site: Buttock, Route: I.M (12)
CL Item
No, Side: Right, Site: Buttock, Route: S.C (13)
Item Group
Vaccine Administration Group Control
C2368628 (UMLS CUI-1)
C0009932 (UMLS CUI-2)
Subject number
Item
Subject number
integer
C2348585 (UMLS CUI [1])
date vaccine administration
Item
Please complete only if different from visit date :
date
C0011008 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
Item
Vaccine administration MenC Vaccine
text
C2368628 (UMLS CUI [1,1])
C1720015 (UMLS CUI [1,2])
Vaccine administration Meningococcal vaccine
Code List
Vaccine administration MenC Vaccine
CL Item
MenC Vaccine (MenC Vaccine)
CL Item
Replacement vial (Replacement vial)
CL Item
Wrong vial number (Wrong vial number)
CL Item
Not administered (Not administered)
comment
Item
If Replacement vial, comment
text
C0947611 (UMLS CUI [1])
Item
Has the study vaccine been administered according to the Protocol ?
text
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
C0013153 (UMLS CUI [1,3])
C0441987 (UMLS CUI [1,4])
vaccine administration site route side
Code List
Has the study vaccine been administered according to the Protocol ?
CL Item
Yes (1)
CL Item
No, Side: Left, Site: Deltoid, Route: I.M (2)
CL Item
No, Side: Left, Site: Deltoid, Route: S.C (3)
CL Item
No, Side: Right, Site: Deltoid, Route: I.M (4)
CL Item
No, Side: Right, Site: Deltoid, Route: S.C (5)
CL Item
No, Side: Left, Site: Thigh, Route: I:M (6)
CL Item
No, Side: Left, Site: Thigh, Route: S.C (7)
CL Item
No, Side: Right, Site: Thigh, Route: I.M (8)
CL Item
No, Side: Right, Site: Thigh, Route: S.C (9)
CL Item
No, Side: Left, Site: Buttock, Route: I.M (10)
CL Item
No, Side: Left, Site: Buttock, Route: S.C (11)
CL Item
No, Side: Right, Site: Buttock, Route: I.M (12)
CL Item
No, Side: Right, Site: Buttock, Route: S.C (13)
Item
Vaccine administration DTPa-HBV-IPV/Hib Vaccine
text
C2368628 (UMLS CUI [1,1])
C1121707 (UMLS CUI [1,2])
vaccine administration DTPa-HBV-IPV/Hib Vaccine
Code List
Vaccine administration DTPa-HBV-IPV/Hib Vaccine
CL Item
DTPa-HBV-IPV/Hib Vaccine (DTPa-HBV-IPV/Hib Vaccine)
CL Item
Replacement vial (Replacement vial)
CL Item
Wrong vial number (Wrong vial number)
CL Item
Not administered (Not administered)
comment
Item
If Replacement vial, comment
text
C0947611 (UMLS CUI [1])
Item
Has the study vaccine been administered according to the Protocol ?
text
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
C0013153 (UMLS CUI [1,3])
C0441987 (UMLS CUI [1,4])
vaccine administration site route side
Code List
Has the study vaccine been administered according to the Protocol ?
CL Item
Yes (1)
CL Item
No, Side: Left, Site: Deltoid, Route: I.M (2)
CL Item
No, Side: Left, Site: Deltoid, Route: S.C (3)
CL Item
No, Side: Right, Site: Deltoid, Route: I.M (4)
CL Item
No, Side: Right, Site: Deltoid, Route: S.C (5)
CL Item
No, Side: Left, Site: Thigh, Route: I:M (6)
CL Item
No, Side: Left, Site: Thigh, Route: S.C (7)
CL Item
No, Side: Right, Site: Thigh, Route: I.M (8)
CL Item
No, Side: Right, Site: Thigh, Route: S.C (9)
CL Item
No, Side: Left, Site: Buttock, Route: I.M (10)
CL Item
No, Side: Left, Site: Buttock, Route: S.C (11)
CL Item
No, Side: Right, Site: Buttock, Route: I.M (12)
CL Item
No, Side: Right, Site: Buttock, Route: S.C (13)
Item Group
Why not administered ?
C2368628 (UMLS CUI-1)
C0205544 (UMLS CUI-2)
Item
Why not administered ?
text
C2368628 (UMLS CUI [1,1])
C0205544 (UMLS CUI [1,2])
Vaccine administration cancelled
Code List
Why not administered ?
CL Item
SAE) Serious adverse event (complete the Serious Adverse Event form (SAE) Serious adverse event (complete the Serious Adverse Event form)
CL Item
AEX) Non-Serious adverse event (complete the Non-serious Adverse Event form (AEX) Non-Serious adverse event (complete the Non-serious Adverse Event form)
CL Item
OTH) Other (OTH) Other)
SAE
Item
If SAE, Please specify SAE N° :
text
C1519255 (UMLS CUI [1])
non serious adverse event
Item
If AEX, Please specify AE N° (Unsolicited) or code (Solicited) : :
text
C1518404 (UMLS CUI [1])
Other
Item
If other, please specify
text
C0205394 (UMLS CUI [1])
Item
Please tick who took the decision :
text
C0027361 (UMLS CUI [1])
person Vaccine administration cancelled
Code List
Please tick who took the decision :
CL Item
Investigator (Investigator)
C2826892 (UMLS CUI-1)
(Comment:en)
CL Item
Parents/Guardians (Parents/Guardians)
C0030551 (UMLS CUI-1)
(Comment:en)
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video