ID

24822

Description

Study part: Patient Enrollment Form Patient Continuation/ Withdrawal. 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. 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. Study ID: 101468/192. Clinical Study ID: 101468/192

Keywords

Versions (2)
  1. 8/19/17 8/19/17 -
  2. 3/13/19 3/13/19 -
Copyright Holder

GlaxoSmithKline

Uploaded on

August 19, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Patient Enrollment Form Patient Continuation/ Withdrawal Ropinirole Restless Legs Syndrom 101468/192

English

Patient Enrollment Form Patient Continuation/ Withdrawal

1 forms  
PATIENT ENROLMENT FORM
Description

PATIENT ENROLMENT FORM

Alias
UMLS CUI-1
C4041024
To
Description

Received By

Data type

text

Alias
UMLS CUI [1]
C1709850
Fax No.:
Description

Fax Number

Data type

integer

Alias
UMLS CUI [1]
C1549619
The following patient has been enroled in study: 101468/
Description

study subject participation status

Data type

integer

Alias
UMLS CUI [1]
C2348568
Patient Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Patient Number
Description

Patient Number

Data type

integer

Alias
UMLS CUI [1]
C1830427
Centre Number
Description

Centre Number

Data type

integer

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0019994
Date of enrollment:
Description

Date of enrollment

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0679646
UMLS CUI [1,3]
C1516879
Signed:
Description

Signed

Data type

text

Alias
UMLS CUI [1]
C1561610
Date:
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Please print name:
Description

print name

Data type

text

Alias
UMLS CUI [1]
C0027365
Institution:
Description

Institution

Data type

text

Alias
UMLS CUI [1]
C1301943
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Similar models

Patient Enrollment Form Patient Continuation/ Withdrawal

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
PATIENT ENROLMENT FORM
C4041024 (UMLS CUI-1)
Received By
Item
To
text
C1709850 (UMLS CUI [1])
Fax Number
Item
Fax No.:
integer
C1549619 (UMLS CUI [1])
study subject participation status
Item
The following patient has been enroled in study: 101468/
integer
C2348568 (UMLS CUI [1])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Patient Number
Item
Patient Number
integer
C1830427 (UMLS CUI [1])
Centre Number
Item
Centre Number
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Date of enrollment
Item
Date of enrollment:
date
C0011008 (UMLS CUI [1,1])
C0679646 (UMLS CUI [1,2])
C1516879 (UMLS CUI [1,3])
Signed
Item
Signed:
text
C1561610 (UMLS CUI [1])
Date
Item
Date:
date
C0011008 (UMLS CUI [1])
print name
Item
Please print name:
text
C0027365 (UMLS CUI [1])
Institution
Item
Institution:
text
C1301943 (UMLS CUI [1])
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