ID

24289

Beschrijving

Study medication and compliance record, Dose reductions due to adverse experience, Medical procedures, concomitant medication, Non-serious adverse event from Module 3 - Baseline, Day 2, Wk 1-8-Cont/Wthd 101468/243 Study ID: 101468/243 Clinical Study ID: 101468/243 Study Title: A 52 Week Open-Label Extension Study of the Long-Term Safety of Ropinirole in Subjects Suffering from Restless Legs Syndrome (RLS) Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: N/A Sponsor:GlaxoSmithKline Collaborators: N/A Phase: Phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Modutab,ZIPEREVE,ZEPREVE,REPREVE,ADARTREL,REQUIP,Zygara; Zygara,ZIPEREVE,ZEPREVE,Requip Depot,REQUIP,REPREVE,Modutab,ADARTREL Study Indication: Restless Legs Syndrome

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Versies (1)
  1. 28-07-17 28-07-17 -
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glaxoSmithKline

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28 juli 2017

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GSK study: Ropinirole in RLS patients 101468/243 - Additional forms (Week 1-8)

Engels

GSK study: Ropinirole in RLS patients 101468/243 - Additional forms (Week 1-8)

1 Formulieren  
Study medication and compliance record
Beschrijving

Study medication and compliance record

Alias
UMLS CUI-1
C2734539
UMLS CUI-2
C0008972
UMLS CUI-3
C1321605
Study Medication Week number
Beschrijving

Study Medication Week number

Datatype

integer

Alias
UMLS CUI [1,1]
C0439230
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0008972
Dose Level
Beschrijving

Specify 1 - 8

Datatype

integer

Alias
UMLS CUI [1]
C0178602
Date of first dose
Beschrijving

First Dose Date

Datatype

date

Alias
UMLS CUI [1]
C3173309
Date of last dose
Beschrijving

Date last dose

Datatype

date

Alias
UMLS CUI [1]
C1762893
Number of tablets dispensed
Beschrijving

Number of tablets dispensed

Datatype

integer

Alias
UMLS CUI [1,1]
C0805077
UMLS CUI [1,2]
C0304229
Number of tablets returned
Beschrijving

Number of tablets returned

Datatype

integer

Alias
UMLS CUI [1,1]
C2699071
UMLS CUI [1,2]
C0304229
Dose reductions due to adverse experience
Beschrijving

Dose reductions due to adverse experience

Alias
UMLS CUI-1
C1707814
UMLS CUI-2
C0559546
Study Medication Week number
Beschrijving

specify

Datatype

integer

Maateenheden
  • 1
Alias
UMLS CUI [1,1]
C0439230
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0008972
1
Dose Level
Beschrijving

Specify 1 - 8

Datatype

integer

Alias
UMLS CUI [1]
C0178602
Date of first dose
Beschrijving

First Dose Date

Datatype

date

Alias
UMLS CUI [1]
C3173309
Date of last dose
Beschrijving

Date last dose

Datatype

date

Alias
UMLS CUI [1]
C1762893
Number of tablets dispensed
Beschrijving

Number of tablets dispensed

Datatype

integer

Alias
UMLS CUI [1,1]
C0805077
UMLS CUI [1,2]
C0304229
Number of tablets returned
Beschrijving

Number of tablets returned

Datatype

integer

Alias
UMLS CUI [1,1]
C2699071
UMLS CUI [1,2]
C0304229
Medical procedures
Beschrijving

Medical procedures

Alias
UMLS CUI-1
C0199171
Have any non-medication, therapeutic, diagnostic or surgical procedures been performed during the module?
Beschrijving

If 'Yes', please record details below using standard medical terminology

Datatype

integer

Alias
UMLS CUI [1]
C0199171
UMLS CUI [2]
C0087111
UMLS CUI [3]
C0430022
UMLS CUI [4]
C0543467
Medical procedures
Beschrijving

Medical procedures

Alias
UMLS CUI-1
C0199171
Procedure
Beschrijving

C0199171

Datatype

text

Indication
Beschrijving

All indications for procedures should be recorded in either the Adverse Experiences and/or SAE sections as appropriate.

Datatype

text

Alias
UMLS CUI [1,1]
C0199171
UMLS CUI [1,2]
C3146298
Procedure Start Date
Beschrijving

Procedure Start Date

Datatype

date

Alias
UMLS CUI [1,1]
C0199171
UMLS CUI [1,2]
C0808070
End Date Procedure
Beschrijving

End Date Procedure

Datatype

date

Alias
UMLS CUI [1,1]
C0199171
UMLS CUI [1,2]
C0806020
Concomitant medication
Beschrijving

Concomitant medication

Alias
UMLS CUI-1
C2347852
Please mark with 'yes', if there has been no new or change in concomitant medication during the module
Beschrijving

Mark box below or complete page with concomitant medication details (Please print clearly).

Datatype

boolean

Alias
UMLS CUI [1]
C2347852
Concomitant medication
Beschrijving

Concomitant medication

Alias
UMLS CUI-1
C2347852
Drug name (Trade name preferred)
Beschrijving

Drug name

Datatype

text

Alias
UMLS CUI [1]
C0013227
Total Daily Dose
Beschrijving

eg. 500 mg

Datatype

text

Alias
UMLS CUI [1]
C2348070
Medical Illness/ Diagnosis (or symptom in absence of diagnosis)
Beschrijving

Any new medical illness/diagnosis (or symptoms in the absence of a diagnosis) should be recorded in the Adverse Experiences and/or SAE sections as appropriate using the same terminology.

Datatype

text

Alias
UMLS CUI [1]
C0011900
Start Date (be as precise as possible)
Beschrijving

start date of medication

Datatype

date

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0808070
End Date
Beschrijving

End Date of medication

Datatype

date

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0806020
Does the medication still continue?
Beschrijving

If a medication was marked ‘Continuing’ at a previous visit, but has since had a dosage change or has been stopped, it must be recorded as a change below with the new start and end date.

Datatype

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0521116
Adverse experience (non-serious)
Beschrijving

Adverse experience (non-serious)

Alias
UMLS CUI-1
C1518404
Please mark this box if no adverse experiences occurred during the module.
Beschrijving

Record any adverse experiences (using standard medical terminology) observed or elicited by the following direct question to patient: “Have you felt different in any way since starting the treatment or since the last visit?” Provide the diagnosis, not symptoms, where possible. One adverse experience per column. If you consider this to be a serious adverse experience (SAE), please do not enter on this page but enter in the Serious Adverse Experience (SAE) section (See opposite for definitions of an SAE).

Datatype

boolean

Alias
UMLS CUI [1]
C1518404
Adverse experience (non-serious)
Beschrijving

Adverse experience (non-serious)

Alias
UMLS CUI-1
C1518404
Adverse experience
Beschrijving

Record any adverse experiences (using standard medical terminology) observed or elicited by the following direct question to patient: “Have you felt different in any way since starting the treatment or since the last visit?” Provide the diagnosis, not symptoms, where possible. One adverse experience per column.

Datatype

text

Alias
UMLS CUI [1]
C1518404
Onset Date and Time
Beschrijving

Adverse Event Start Date Time

Datatype

datetime

Alias
UMLS CUI [1]
C2826806
End Date and Time
Beschrijving

(If ongoing please leave blank)

Datatype

datetime

Alias
UMLS CUI [1]
C2826793
Outcome
Beschrijving

If patient died, STOP: go to SAE section and follow instructions given there

Datatype

integer

Alias
UMLS CUI [1]
C1705586
Experience Course
Beschrijving

adverse event course

Datatype

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0750729
Number of episodes
Beschrijving

only answer if previous answer was 'intermittent'

Datatype

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C4086638
Intensity (maximum)
Beschrijving

Intensity concerning the maximum

Datatype

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0518690
Action Taken with Respect to Investigational Drug
Beschrijving

Action Taken with Respect to Investigational Drug

Datatype

text

Alias
UMLS CUI [1]
C2826626
Relationship to Investigational Drug
Beschrijving

Relationship to Investigational Drug

Datatype

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0013230
UMLS CUI [1,3]
C0439849
Corrective Therapy
Beschrijving

f ‘Yes’, record details in the Concomitant Medication section and/ or Healthcare Resource Utilisation form if appropriate

Datatype

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Was patient withdrawn due to this specific AE?
Beschrijving

Was patient withdrawn due to this specific AE?

Datatype

boolean

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C1518404
Pregnancy information
Beschrijving

Pregnancy information

Alias
UMLS CUI-1
C0032961
Has the patient become pregnant to date?
Beschrijving

If ’Yes’ please record details on the Pregnancy Notification Form, if not already completed and withdraw the patient.

Datatype

text

Alias
UMLS CUI [1]
C0032961
Patient continuation/ withdrawal
Beschrijving

Patient continuation/ withdrawal

Alias
UMLS CUI-1
C2348568
Is the patient continuing in the study?
Beschrijving

If ’No’, please mark the primary cause of withdrawal.

Datatype

boolean

Alias
UMLS CUI [1,1]
C0008976
UMLS CUI [1,2]
C0549178
Cause of withdrawal from study
Beschrijving

Cause of withdrawal from study

Datatype

integer

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0085978
Please specify 'other' cause of withdrawal from study.
Beschrijving

Other cause of withdrawal from study

Datatype

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0205394
Investigator signature
Beschrijving

Investigator signature

Alias
UMLS CUI-1
C2346576
Investigator signature
Beschrijving

I certify that I have reviewed the data in this Case Report Form, including laboratory data and that in the Adverse Experience and Serious Adverse Experience sections (if appropriate) and that all information is complete and accurate.

Datatype

text

Alias
UMLS CUI [1]
C2346576
Date of Investigator signature
Beschrijving

Investigator signature date

Datatype

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
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Similar models

GSK study: Ropinirole in RLS patients 101468/243 - Additional forms (Week 1-8)

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Study medication and compliance record
C2734539 (UMLS CUI-1)
C0008972 (UMLS CUI-2)
C1321605 (UMLS CUI-3)
Item
Study Medication Week number
integer
C0439230 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0008972 (UMLS CUI [1,3])
undefined item
Code List
Study Medication Week number
CL Item
Week 1 (Day 1-2) (1)
CL Item
Week 1 (Day 3-7) (2)
CL Item
Week 2 (3)
CL Item
Week 3 (4)
CL Item
Week 4 (5)
CL Item
Week 5 (6)
CL Item
Week 6 (7)
CL Item
Week 7 (8)
CL Item
Week 8 (9)
Dose Level
Item
Dose Level
integer
C0178602 (UMLS CUI [1])
First Dose Date
Item
Date of first dose
date
C3173309 (UMLS CUI [1])
Date last dose
Item
Date of last dose
date
C1762893 (UMLS CUI [1])
Number of tablets dispensed
Item
Number of tablets dispensed
integer
C0805077 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
Number of tablets returned
Item
Number of tablets returned
integer
C2699071 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
Item Group
Dose reductions due to adverse experience
C1707814 (UMLS CUI-1)
C0559546 (UMLS CUI-2)
Study Medication Week number
Item
Study Medication Week number
integer
C0439230 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0008972 (UMLS CUI [1,3])
Dose Level
Item
Dose Level
integer
C0178602 (UMLS CUI [1])
First Dose Date
Item
Date of first dose
date
C3173309 (UMLS CUI [1])
Date last dose
Item
Date of last dose
date
C1762893 (UMLS CUI [1])
Number of tablets dispensed
Item
Number of tablets dispensed
integer
C0805077 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
Number of tablets returned
Item
Number of tablets returned
integer
C2699071 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
Item Group
Medical procedures
C0199171 (UMLS CUI-1)
Item
Have any non-medication, therapeutic, diagnostic or surgical procedures been performed during the module?
integer
C0199171 (UMLS CUI [1])
C0087111 (UMLS CUI [2])
C0430022 (UMLS CUI [3])
C0543467 (UMLS CUI [4])
medical procedures
Code List
Have any non-medication, therapeutic, diagnostic or surgical procedures been performed during the module?
CL Item
no (1)
CL Item
yes (2)
Item Group
Medical procedures
C0199171 (UMLS CUI-1)
Procedure
Item
Procedure
text
Indication of medical procedure
Item
Indication
text
C0199171 (UMLS CUI [1,1])
C3146298 (UMLS CUI [1,2])
Procedure Start Date
Item
Procedure Start Date
date
C0199171 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
End Date Procedure
Item
End Date Procedure
date
C0199171 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Item Group
Concomitant medication
C2347852 (UMLS CUI-1)
Concomitant medication
Item
Please mark with 'yes', if there has been no new or change in concomitant medication during the module
boolean
C2347852 (UMLS CUI [1])
Item Group
Concomitant medication
C2347852 (UMLS CUI-1)
Drug name
Item
Drug name (Trade name preferred)
text
C0013227 (UMLS CUI [1])
Total Daily Dose
Item
Total Daily Dose
text
C2348070 (UMLS CUI [1])
Diagnosis
Item
Medical Illness/ Diagnosis (or symptom in absence of diagnosis)
text
C0011900 (UMLS CUI [1])
start date of medication
Item
Start Date (be as precise as possible)
date
C0013227 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
End Date of medication
Item
End Date
date
C0013227 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
medication is current
Item
Does the medication still continue?
boolean
C0013227 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Item Group
Adverse experience (non-serious)
C1518404 (UMLS CUI-1)
Non-serious adverse event
Item
Please mark this box if no adverse experiences occurred during the module.
boolean
C1518404 (UMLS CUI [1])
Item Group
Adverse experience (non-serious)
C1518404 (UMLS CUI-1)
Non-serious adverse event
Item
Adverse experience
text
C1518404 (UMLS CUI [1])
Adverse Event Start Date Time
Item
Onset Date and Time
datetime
C2826806 (UMLS CUI [1])
Adverse Event End Date Time
Item
End Date and Time
datetime
C2826793 (UMLS CUI [1])
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Adverse Event Outcome
Code List
Outcome
CL Item
resolved (1)
CL Item
ongoing (2)
CL Item
died (3)
Item
Experience Course
integer
C0877248 (UMLS CUI [1,1])
C0750729 (UMLS CUI [1,2])
adverse event course
Code List
Experience Course
CL Item
intermittent (1)
CL Item
constant (2)
Number of episodes of adverse event
Item
Number of episodes
integer
C0877248 (UMLS CUI [1,1])
C4086638 (UMLS CUI [1,2])
Item
Intensity (maximum)
integer
C0877248 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Intensity of the adverse event
Code List
Intensity (maximum)
CL Item
mild (1)
CL Item
moderate (2)
CL Item
severe (3)
Item
Action Taken with Respect to Investigational Drug
text
C2826626 (UMLS CUI [1])
Action Taken with Respect to Investigational Drug
Code List
Action Taken with Respect to Investigational Drug
CL Item
None (1)
CL Item
Dose reduced (2)
CL Item
Dose increased (3)
CL Item
Drug interrupted/restarted (4)
CL Item
Drug stopped (5)
Item
Relationship to Investigational Drug
integer
C1518404 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Relationship to Investigational Drug
Code List
Relationship to Investigational Drug
CL Item
Related (5)
CL Item
Possibly related (6)
CL Item
Probably unrelated (7)
CL Item
Unrelated (1)
Item
Corrective Therapy
integer
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Corrective therapy to adverse event
Code List
Corrective Therapy
CL Item
yes (1)
CL Item
no (2)
Was patient withdrawn due to this specific AE?
Item
Was patient withdrawn due to this specific AE?
boolean
C0422727 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Item Group
Pregnancy information
C0032961 (UMLS CUI-1)
Item
Has the patient become pregnant to date?
text
C0032961 (UMLS CUI [1])
pregnancy
Code List
Has the patient become pregnant to date?
CL Item
Not applicable (not of childbearing potential or male) (X)
CL Item
No (N)
CL Item
Yes (Y)
Item Group
Patient continuation/ withdrawal
C2348568 (UMLS CUI-1)
Continuing study
Item
Is the patient continuing in the study?
boolean
C0008976 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Item
Cause of withdrawal from study
integer
C0422727 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
Cause of withdrawal from study
Code List
Cause of withdrawal from study
CL Item
Adverse experience (please complete AE page) (1)
CL Item
Insufficient therapeutic effect (2)
CL Item
Protocol deviation (including non-compliance) (3)
CL Item
Lost to follow-up (4)
CL Item
Other-specify (7)
Other cause of withdrawal from study
Item
Please specify 'other' cause of withdrawal from study.
text
C0422727 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Investigator signature
C2346576 (UMLS CUI-1)
investigator signature
Item
Investigator signature
text
C2346576 (UMLS CUI [1])
Investigator signature date
Item
Date of Investigator signature
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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