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GSK study: Ropinirole in RLS patients 101468/243 - Form Death

1 forms  
Death Form
Description

Death Form

Alias
UMLS CUI-1
C1306577
Certified cause of death
Description

Certified cause of death

Data type

text

Alias
UMLS CUI [1]
C3262229
Date of death
Description

Date of death

Data type

date

Alias
UMLS CUI [1]
C1148348
Please complete Serious Adverse Experience section with regard to death.
Description

Please complete Serious Adverse Experience section with regard to death.

Data type

text

Alias
UMLS CUI [1]
C1519255
Was an autopsy carried out?
Description

If ‘Yes’ please summarize findings (include diagnosis):

Data type

boolean

Alias
UMLS CUI [1]
C0004398
Please summarize findings of autopsy (include diagnosis):
Description

Only fill in if you answered previous question with ‘Yes’.

Data type

text

Alias
UMLS CUI [1,1]
C0004398
UMLS CUI [1,2]
C0243095
UMLS CUI [2,1]
C0004398
UMLS CUI [2,2]
C0011900
Reporting Physician’s Signature
Description

Reporting Physician’s Signature

Data type

text

Alias
UMLS CUI [1]
C2346576
Reporting Physician’s Signature Date
Description

Investigator signature date

Data type

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 - Form Death

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Death Form
C1306577 (UMLS CUI-1)
Certified cause of death
Item
Certified cause of death
text
C3262229 (UMLS CUI [1])
Date of death
Item
Date of death
date
C1148348 (UMLS CUI [1])
Serious Adverse Event
Item
Please complete Serious Adverse Experience section with regard to death.
text
C1519255 (UMLS CUI [1])
autopsy
Item
Was an autopsy carried out?
boolean
C0004398 (UMLS CUI [1])
autopsy findings
Item
Please summarize findings of autopsy (include diagnosis):
text
C0004398 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0004398 (UMLS CUI [2,1])
C0011900 (UMLS CUI [2,2])
Reporting Physician’s Signature
Item
Reporting Physician’s Signature
text
C2346576 (UMLS CUI [1])
Investigator signature date
Item
Reporting Physician’s Signature Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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