Englisch

GSK Hepatitis A Vaccine MONTH 174 VISIT 21 SERIOUS ADVERSE EVENT NCT00291876

1 Formulare  
Study administration
Beschreibung

Study administration

Center
Beschreibung

Center

Datentyp

text

Alias
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0600091
Country
Beschreibung

Country

Datentyp

text

Alias
UMLS CUI [1]
C0454664
GS Receipt Date
Beschreibung

Receipt Date

Datentyp

date

Alias
UMLS CUI [1]
C2985846
Subject Number
Beschreibung

Subject Identifier

Datentyp

integer

Alias
UMLS CUI [1]
C2348585
SERIOUS ADVERSE EVENT (SAE)
Beschreibung

SERIOUS ADVERSE EVENT (SAE)

SERIOUS ADVERSE EVENT (SAE)
Beschreibung

Serious adverse event

Datentyp

text

Alias
UMLS CUI [1]
C1519255
Subject Demography
Beschreibung

Subject Demography

Initials
Beschreibung

Initials

Datentyp

text

Maßeinheiten
  • _ _ First Name / _ _ Family Name
Alias
UMLS CUI [1]
C2986440
_ _ First Name / _ _ Family Name
Date of birth
Beschreibung

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Gender
Beschreibung

Gender

Datentyp

integer

Alias
UMLS CUI [1]
C0079399
Adverse Event Diagnosis (or signs and symptoms if not known)
Beschreibung

Adverse Event

Datentyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0011900
For GSK
Beschreibung

For GSK

Date and time started:
Beschreibung

(Adverse event first symptoms)

Datentyp

datetime

Alias
UMLS CUI [1]
C2697888
Date and time stopped:
Beschreibung

(If ongoing please leave blank)

Datentyp

datetime

Alias
UMLS CUI [1]
C2697886
Intensity:
Beschreibung

(maximum)

Datentyp

integer

Alias
UMLS CUI [1]
C1710066
In your opinion, did the vaccine possibly contribute to the SAE:
Beschreibung

vaccine causing sae

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
UMLS CUI [1,3]
C0042196
Outcome:
Beschreibung

(maximum)

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Other possible contributors:
Beschreibung

Other possible contributors:

Medical history
Beschreibung

(record in section 15)

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
UMLS CUI [1,3]
C0262926
Other medication
Beschreibung

(record in section 14)

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
UMLS CUI [1,3]
C0013227
Protocol required procedure
Beschreibung

Protocol required procedure

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
UMLS CUI [1,3]
C0184661
Other procedure
Beschreibung

Other procedure

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
UMLS CUI [1,3]
C0393107
Lack of efficacy
Beschreibung

Lack of efficacy

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
UMLS CUI [1,3]
C0235828
Erroneous administration
Beschreibung

Erroneous administration

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
UMLS CUI [1,3]
C0549489
Other, specify:
Beschreibung

Other sae contribution

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
Other, specify:
Beschreibung

Other sae contribution

Datentyp

text

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
Action taken with respect to Study Vaccine
Beschreibung

action taken

Datentyp

integer

Alias
UMLS CUI [1]
C2826626
Events after further vaccination
Beschreibung

further adverse event

Datentyp

integer

Alias
UMLS CUI [1,1]
C0035020
UMLS CUI [1,2]
C0877248
Other events (not SAE) to be reported in the same way: Cancer
Beschreibung

Other events

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C2826307
Was subject withdrawn due to this specific SAE?
Beschreibung

withdrawal

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C1519255
Specify criteria for considering this as a Serious Adverse Event.
Beschreibung

Specify criteria for considering this as a Serious Adverse Event.

Result in death --> Autopsy?
Beschreibung

Send autopsy report when available

Datentyp

boolean

Alias
UMLS CUI [1]
C1320832
Life threatening
Beschreibung

adverse event life threatening

Datentyp

boolean

Alias
UMLS CUI [1]
C1517874
Result in persistent or significant disability/incapacity
Beschreibung

adverse event disability

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0231170
Requires in-patient hospitalization.
Beschreibung

Adverse Event associated with Hospitalization

Datentyp

boolean

Alias
UMLS CUI [1]
C2826664
Admission date:
Beschreibung

admission date

Datentyp

date

Alias
UMLS CUI [1,1]
C1302393
UMLS CUI [1,2]
C1519255
Discharge date
Beschreibung

Discharge date

Datentyp

date

Alias
UMLS CUI [1,1]
C2361123
UMLS CUI [1,2]
C1519255
Prolongation of existing hospitalization
Beschreibung

Prolongation of existing hospitalization

Datentyp

boolean

Alias
UMLS CUI [1]
C0745041
Discharge date
Beschreibung

Discharge date

Datentyp

date

Alias
UMLS CUI [1,1]
C2361123
UMLS CUI [1,2]
C1519255
Congenital anomaly / birth defect in the offspring of a study subject.
Beschreibung

Congenital anomaly

Datentyp

boolean

Alias
UMLS CUI [1]
C2826727
“Medically important” event specify:
Beschreibung

other event

Datentyp

boolean

Alias
UMLS CUI [1]
C1710056
“Medically important” event specify:
Beschreibung

other event

Datentyp

text

Alias
UMLS CUI [1]
C1710056
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Ähnliche Modelle

GSK Hepatitis A Vaccine MONTH 174 VISIT 21 SERIOUS ADVERSE EVENT NCT00291876

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Study administration
Center
Item
Center
text
C1301943 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Country
Item
Country
text
C0454664 (UMLS CUI [1])
Receipt Date
Item
GS Receipt Date
date
C2985846 (UMLS CUI [1])
Subject Identifier
Item
Subject Number
integer
C2348585 (UMLS CUI [1])
Item Group
SERIOUS ADVERSE EVENT (SAE)
Item
SERIOUS ADVERSE EVENT (SAE)
text
C1519255 (UMLS CUI [1])
Serious adverse event
Code List
SERIOUS ADVERSE EVENT (SAE)
CL Item
(1) Initial report ((1) Initial report)
CL Item
(2) Additional info ((2) Additional info)
CL Item
(3) Additional info ((3) Additional info)
CL Item
(4) Additional info ((4) Additional info)
Item Group
Subject Demography
Initials
Item
Initials
text
C2986440 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Gender
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
Male (1)
CL Item
Female (2)
Adverse Event
Item
Adverse Event Diagnosis (or signs and symptoms if not known)
text
C0877248 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item Group
For GSK
adverse event start date
Item
Date and time started:
datetime
C2697888 (UMLS CUI [1])
adverse event end date
Item
Date and time stopped:
datetime
C2697886 (UMLS CUI [1])
Item
Intensity:
integer
C1710066 (UMLS CUI [1])
adverse event intensitiy
Code List
Intensity:
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
vaccine causing sae
Item
In your opinion, did the vaccine possibly contribute to the SAE:
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0042196 (UMLS CUI [1,3])
Item
Outcome:
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome:
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
Item Group
Other possible contributors:
Medical history
Item
Medical history
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0262926 (UMLS CUI [1,3])
Other medication
Item
Other medication
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0013227 (UMLS CUI [1,3])
Protocol required procedure
Item
Protocol required procedure
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0184661 (UMLS CUI [1,3])
Other procedure
Item
Other procedure
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0393107 (UMLS CUI [1,3])
Lack of efficacy
Item
Lack of efficacy
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0235828 (UMLS CUI [1,3])
Erroneous administration
Item
Erroneous administration
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0549489 (UMLS CUI [1,3])
Other sae contribution
Item
Other, specify:
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
Other sae contribution
Item
Other, specify:
text
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
Item
Action taken with respect to Study Vaccine
integer
C2826626 (UMLS CUI [1])
action taken
Code List
Action taken with respect to Study Vaccine
CL Item
None (1)
CL Item
Vaccination course postponed (2)
CL Item
Vaccination course stopped (3)
Item
Events after further vaccination
integer
C0035020 (UMLS CUI [1,1])
C0877248 (UMLS CUI [1,2])
further adverse event
Code List
Events after further vaccination
CL Item
Event reappeared (1)
CL Item
Event did not reappear (2)
CL Item
Unknown at this time (3)
CL Item
Not applicable (4)
Other events
Item
Other events (not SAE) to be reported in the same way: Cancer
boolean
C0006826 (UMLS CUI [1,1])
C2826307 (UMLS CUI [1,2])
withdrawal
Item
Was subject withdrawn due to this specific SAE?
boolean
C2349954 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item Group
Specify criteria for considering this as a Serious Adverse Event.
adverse event results in death
Item
Result in death --> Autopsy?
boolean
C1320832 (UMLS CUI [1])
adverse event life threatening
Item
Life threatening
boolean
C1517874 (UMLS CUI [1])
adverse event disability
Item
Result in persistent or significant disability/incapacity
boolean
C0877248 (UMLS CUI [1,1])
C0231170 (UMLS CUI [1,2])
Adverse Event associated with Hospitalization
Item
Requires in-patient hospitalization.
boolean
C2826664 (UMLS CUI [1])
admission date
Item
Admission date:
date
C1302393 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Discharge date
Item
Discharge date
date
C2361123 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Prolongation of existing hospitalization
Item
Prolongation of existing hospitalization
boolean
C0745041 (UMLS CUI [1])
Discharge date
Item
Discharge date
date
C2361123 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Congenital anomaly
Item
Congenital anomaly / birth defect in the offspring of a study subject.
boolean
C2826727 (UMLS CUI [1])
other event
Item
“Medically important” event specify:
boolean
C1710056 (UMLS CUI [1])
other event
Item
“Medically important” event specify:
text
C1710056 (UMLS CUI [1])
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