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Diary Card - Varicella /Zoster Case - GSK Study: Evaluation of safety and efficacy of VarilrixTM and of Combined Measles-Mumps-Rubella-Varicella Vaccine NCT00226499

1 forms  
Rash
Description

Rash

Alias
UMLS CUI-1
C0015230
Date rash onset
Description

date when first lesion appears

Data type

date

Alias
UMLS CUI [1,1]
C0015230
UMLS CUI [1,2]
C0574845
Date rash end
Description

date of first day when no new lesions appear

Data type

date

Alias
UMLS CUI [1,1]
C0015230
UMLS CUI [1,2]
C0806020
Lesion
Description

Lesion

Alias
UMLS CUI-1
C0221198
Day
Description

Day 0-14 Day 0 should be date rash onset - Complete until date rash end

Data type

integer

Alias
UMLS CUI [1,1]
C0439228
UMLS CUI [1,2]
C0750480
UMLS CUI [1,3]
C0221198
Daily number of overall Lesions
Description

Daily number of overall Lesions

Data type

integer

Alias
UMLS CUI [1,1]
C0221198
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0332173
Vesicles
Description

Vesicles

Alias
UMLS CUI-1
C0333262
Day
Description

Day 0 should be date rash onset - Complete until date rash end

Data type

text

Alias
UMLS CUI [1,1]
C0439228
UMLS CUI [1,2]
C0750480
UMLS CUI [1,3]
C0333262
Daily number of overall Vesicles
Description

Estimation of the DAILY number of vesicles (=lesions with fluid in them) according to the following ranges

Data type

integer

Alias
UMLS CUI [1,1]
C0333262
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0332173
Temperature
Description

Temperature

Alias
UMLS CUI-1
C0039476
Route
Description

Please record all temperatures from date rash onset till date rash end Note: → If multiple measurements during a day, record the highest temperature → Only one route of temperature measurement should be used consistently

Data type

text

Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C1515974
Temperature
Description

Temperature

Alias
UMLS CUI-1
C0039476
Day
Description

Day 0-14 Please record all temperatures from date rash onset till date rash end Note: → If multiple measurements during a day, record the highest temperature → Only one route of temperature measurement should be used consistently

Data type

integer

Alias
UMLS CUI [1,1]
C0439228
UMLS CUI [1,2]
C0750480
UMLS CUI [1,3]
C0039476
Date
Description

Date Temperature

Data type

date

Alias
UMLS CUI [1,1]
C0039476
UMLS CUI [1,2]
C0011008
Temperature
Description

Temperature

Data type

float

Measurement units
  • degree Celsius
Alias
UMLS CUI [1]
C0039476
degree Celsius
Not taken
Description

Temperature not taken

Data type

boolean

Alias
UMLS CUI [1]
C0039476
Weekdays location
Description

Weekdays location

Alias
UMLS CUI-1
C0450429
UMLS CUI-2
C0680189
Daycare
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

boolean

Alias
UMLS CUI [1]
C0008070
Daycare: Frequency: number of days?
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

integer

Alias
UMLS CUI [1,1]
C0008070
UMLS CUI [1,2]
C0439603
Home
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

boolean

Alias
UMLS CUI [1]
C0442519
Home: Frequency: number of days?
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

integer

Alias
UMLS CUI [1,1]
C0442519
UMLS CUI [1,2]
C0439603
School
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

boolean

Alias
UMLS CUI [1]
C0036375
School: Frequency: number of days?
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

integer

Alias
UMLS CUI [1,1]
C0036375
UMLS CUI [1,2]
C0439603
Childminder
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

boolean

Alias
UMLS CUI [1]
C0730005
Childminder: Frequency: number of days?
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

integer

Alias
UMLS CUI [1,1]
C0730005
UMLS CUI [1,2]
C0439603
Number of children at childminder
Description

Number of children at childminder

Data type

integer

Alias
UMLS CUI [1,1]
C0730005
UMLS CUI [1,2]
C0008059
UMLS CUI [1,3]
C0449788
Number of children with negative varicella history?
Description

at childminder

Data type

integer

Alias
UMLS CUI [1,1]
C0008059
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0455469
Number of children with negative varicella history unknown.
Description

Number of children with negative varicella history unknown

Data type

boolean

Alias
UMLS CUI [1,1]
C0008059
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0455469
Other, specify:
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

text

Alias
UMLS CUI [1,1]
C0450429
UMLS CUI [1,2]
C0205394
UMLS CUI [1,3]
C1521902
Other location
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

boolean

Alias
UMLS CUI [1,1]
C0450429
UMLS CUI [1,2]
C0205394
Other location: Frequency: number of days?
Description

Record whereabouts of your child during daytime for 30 days prior to onset of varicella (chickenpox) rash or zoster case (shingles).

Data type

integer

Alias
UMLS CUI [1,1]
C0450429
UMLS CUI [1,2]
C0205394
UMLS CUI [1,3]
C0439603
Varicella or zoster index case
Description

Varicella or zoster index case

Alias
UMLS CUI-1
C2597943
UMLS CUI-2
C0008049
UMLS CUI-4
C2597943
UMLS CUI-5
C0740380
In last 30 days - prior to onset of varicella (chickenpox) or zoster case (shingles) - was there a recognized exposure of the subject with an index case, was there a recognized exposure of your child with index case?
Description

Varicella or zoster index case

Data type

boolean

Alias
UMLS CUI [1,1]
C2597943
UMLS CUI [1,2]
C0008049
UMLS CUI [2,1]
C2597943
UMLS CUI [2,2]
C0740380
Type of contact
Description

Type of contact

Data type

integer

Alias
UMLS CUI [1,1]
C0332158
UMLS CUI [1,2]
C0332307
Frequency
Description

Frequency of contact

Data type

integer

Alias
UMLS CUI [1,1]
C0008049
UMLS CUI [1,2]
C0332158
UMLS CUI [1,3]
C0439603
Date of contact
Description

Only answer if you choose "occasional contact"

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0332158
UMLS CUI [1,3]
C0008049
Nature of contact
Description

Nature of contact

Data type

integer

Alias
UMLS CUI [1,1]
C0392367
UMLS CUI [1,2]
C0332307
Other: specify
Description

Specify other kind of contact

Data type

text

Alias
UMLS CUI [1,1]
C0392367
UMLS CUI [1,2]
C0205394
UMLS CUI [1,3]
C1521902
Date varicella or zoster end
Description

Date varicella or zoster end

Alias
UMLS CUI-1
C0008049
UMLS CUI-2
C0806020
UMLS CUI-4
C0740380
UMLS CUI-5
C0806020
Date end of varicella (chickenpox)/ zoster (shingles)
Description

date when subject resumes normal everyday activities.

Data type

date

Alias
UMLS CUI [1,1]
C0008049
UMLS CUI [1,2]
C0806020
UMLS CUI [2,1]
C0740380
UMLS CUI [2,2]
C0806020
Health economics
Description

Health economics

Alias
UMLS CUI-1
C0013556
UMLS CUI-2
C0018684
Did you, as parent/guardian, or your family members, lose time from work as a result of taking care of your child during this illness?
Description

work time lost due to care taking

Data type

boolean

Alias
UMLS CUI [1,1]
C0237107
UMLS CUI [1,2]
C0012634
UMLS CUI [1,3]
C0585074
How many hours?
Description

Only answer if you answered previous question with 'yes'. How many hours did the parents/guardians or family members lose time from work as a result of taking care of the subject during this illness ?

Data type

integer

Alias
UMLS CUI [1,1]
C0439227
UMLS CUI [1,2]
C1265611
UMLS CUI [1,3]
C0030551
Did your child lose any days in the day care / childminder / school attendance or any extra-curricular activities (e.g. sports or recreation or any type of organized leisure activities) during this illness?
Description

time lost at day care / childminder / school attendance / extracurricular activity

Data type

boolean

Alias
UMLS CUI [1,1]
C2185951
UMLS CUI [1,2]
C0008070
UMLS CUI [2,1]
C2185951
UMLS CUI [2,2]
C0730005
UMLS CUI [3,1]
C2185951
UMLS CUI [3,2]
C0036375
UMLS CUI [4,1]
C2185951
UMLS CUI [4,2]
C0681383
How many hours?
Description

Only answer if you answered previous question with 'yes'. How many hours did the subject lose in the day care / childminder / school attendance or at extra-curricular activities (e.g. sports or recreation or any type of organised leisure activities) during this illness?

Data type

integer

Alias
UMLS CUI [1,1]
C0439227
UMLS CUI [1,2]
C1265611
UMLS CUI [1,3]
C0008059
Did you request assistance from a nurse, a babysitter or any type of paid caregiver to look after your child during this illness?
Description

Assistance needed by nurse, babysitter or any type of paid caregiver

Data type

boolean

Alias
UMLS CUI [1,1]
C3840284
UMLS CUI [1,2]
C0028661
UMLS CUI [2,1]
C3840284
UMLS CUI [2,2]
C0337606
UMLS CUI [3,1]
C3840284
UMLS CUI [3,2]
C0085537
How many hours?
Description

How many hours did the parents / guardians request assistance from a nurse, a babysitter or any type of paid caregiver to look after the subject during this illness?

Data type

integer

Alias
UMLS CUI [1,1]
C0439227
UMLS CUI [1,2]
C1265611
UMLS CUI [1,3]
C0085537
If your child were not participating in this trial, would you, as parents / guardians, have contacted or visited a physician to seek medical advice for this illness?
Description

Parents seeking medical advice for illness

Data type

boolean

Alias
UMLS CUI [1,1]
C1386497
UMLS CUI [1,2]
C0030551
UMLS CUI [1,3]
C2348568
Pain
Description

Pain

Alias
UMLS CUI-1
C0030193
Did the child present any back or abdominal pain during this illness?
Description

back or abdominal pain varicella or zoster

Data type

boolean

Alias
UMLS CUI [1,1]
C0004604
UMLS CUI [1,2]
C0008049
UMLS CUI [1,3]
C0740380
UMLS CUI [2,1]
C0000737
UMLS CUI [2,2]
C0008049
UMLS CUI [2,3]
C0740380
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Similar models

Diary Card - Varicella /Zoster Case - GSK Study: Evaluation of safety and efficacy of VarilrixTM and of Combined Measles-Mumps-Rubella-Varicella Vaccine NCT00226499

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Rash
C0015230 (UMLS CUI-1)
Date rash onset
Item
Date rash onset
date
C0015230 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
Date rash end
Item
Date rash end
date
C0015230 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Item Group
Lesion
C0221198 (UMLS CUI-1)
Day
Item
Day
integer
C0439228 (UMLS CUI [1,1])
C0750480 (UMLS CUI [1,2])
C0221198 (UMLS CUI [1,3])
Item
Daily number of overall Lesions
integer
C0221198 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0332173 (UMLS CUI [1,3])
Daily number of overall Lesions
Code List
Daily number of overall Lesions
CL Item
1-50 (1)
CL Item
51-100 (2)
CL Item
101-500 (3)
CL Item
>500 (4)
Item Group
Vesicles
C0333262 (UMLS CUI-1)
Day
Item
Day
text
C0439228 (UMLS CUI [1,1])
C0750480 (UMLS CUI [1,2])
C0333262 (UMLS CUI [1,3])
Item
Daily number of overall Vesicles
integer
C0333262 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0332173 (UMLS CUI [1,3])
undefined item
Code List
Daily number of overall Vesicles
CL Item
None (1)
CL Item
1-10 (2)
CL Item
11-50 (3)
CL Item
>50 (4)
Item Group
Temperature
C0039476 (UMLS CUI-1)
Item
Route
text
C0005903 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
Route body temperature
Code List
Route
CL Item
Axillary (A)
CL Item
Rectal (R)
Item Group
Temperature
C0039476 (UMLS CUI-1)
Day
Item
Day
integer
C0439228 (UMLS CUI [1,1])
C0750480 (UMLS CUI [1,2])
C0039476 (UMLS CUI [1,3])
Date Temperature
Item
Date
date
C0039476 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Temperature
Item
Temperature
float
C0039476 (UMLS CUI [1])
Temperature not taken
Item
Not taken
boolean
C0039476 (UMLS CUI [1])
Item Group
Weekdays location
C0450429 (UMLS CUI-1)
C0680189 (UMLS CUI-2)
Daycare
Item
Daycare
boolean
C0008070 (UMLS CUI [1])
Frequency of time spend in daycare
Item
Daycare: Frequency: number of days?
integer
C0008070 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
Home
Item
Home
boolean
C0442519 (UMLS CUI [1])
Frequency of time spend at home
Item
Home: Frequency: number of days?
integer
C0442519 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
School
Item
School
boolean
C0036375 (UMLS CUI [1])
Frequency of time spend at school
Item
School: Frequency: number of days?
integer
C0036375 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
Childminder
Item
Childminder
boolean
C0730005 (UMLS CUI [1])
Frequency of time spend at childminder
Item
Childminder: Frequency: number of days?
integer
C0730005 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
Number of children at childminder
Item
Number of children at childminder
integer
C0730005 (UMLS CUI [1,1])
C0008059 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
Number of children with negative varicella history
Item
Number of children with negative varicella history?
integer
C0008059 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0455469 (UMLS CUI [1,3])
Number of children with negative varicella history unknown
Item
Number of children with negative varicella history unknown.
boolean
C0008059 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0455469 (UMLS CUI [1,3])
specify other location
Item
Other, specify:
text
C0450429 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Other location
Item
Other location
boolean
C0450429 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Frequency of time spend at other location
Item
Other location: Frequency: number of days?
integer
C0450429 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0439603 (UMLS CUI [1,3])
Item Group
Varicella or zoster index case
C2597943 (UMLS CUI-1)
C0008049 (UMLS CUI-2)
C2597943 (UMLS CUI-4)
C0740380 (UMLS CUI-5)
Varicella or zoster index case
Item
In last 30 days - prior to onset of varicella (chickenpox) or zoster case (shingles) - was there a recognized exposure of the subject with an index case, was there a recognized exposure of your child with index case?
boolean
C2597943 (UMLS CUI [1,1])
C0008049 (UMLS CUI [1,2])
C2597943 (UMLS CUI [2,1])
C0740380 (UMLS CUI [2,2])
Item
Type of contact
integer
C0332158 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Type of contact
Code List
Type of contact
CL Item
Varicella (1)
CL Item
Zoster (2)
Item
Frequency
integer
C0008049 (UMLS CUI [1,1])
C0332158 (UMLS CUI [1,2])
C0439603 (UMLS CUI [1,3])
Frequency of contact
Code List
Frequency
CL Item
Occasional contact (1)
CL Item
Daily contact (2)
Date of contact
Item
Date of contact
date
C0011008 (UMLS CUI [1,1])
C0332158 (UMLS CUI [1,2])
C0008049 (UMLS CUI [1,3])
Item
Nature of contact
integer
C0392367 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Nature of contact
Code List
Nature of contact
CL Item
Household (1)
CL Item
Daycare center (2)
CL Item
Childminder (3)
CL Item
Playmate (4)
CL Item
School (in the same building) (5)
CL Item
School (in a different building) (6)
CL Item
Classroom (7)
CL Item
Other: specify (8)
Specify other kind of contact
Item
Other: specify
text
C0392367 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item Group
Date varicella or zoster end
C0008049 (UMLS CUI-1)
C0806020 (UMLS CUI-2)
C0740380 (UMLS CUI-4)
C0806020 (UMLS CUI-5)
End Date Varicella or zoster
Item
Date end of varicella (chickenpox)/ zoster (shingles)
date
C0008049 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
C0740380 (UMLS CUI [2,1])
C0806020 (UMLS CUI [2,2])
Item Group
Health economics
C0013556 (UMLS CUI-1)
C0018684 (UMLS CUI-2)
work time lost due to care taking
Item
Did you, as parent/guardian, or your family members, lose time from work as a result of taking care of your child during this illness?
boolean
C0237107 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0585074 (UMLS CUI [1,3])
Amount of hours
Item
How many hours?
integer
C0439227 (UMLS CUI [1,1])
C1265611 (UMLS CUI [1,2])
C0030551 (UMLS CUI [1,3])
time lost at day care / childminder / school attendance / extracurricular activity
Item
Did your child lose any days in the day care / childminder / school attendance or any extra-curricular activities (e.g. sports or recreation or any type of organized leisure activities) during this illness?
boolean
C2185951 (UMLS CUI [1,1])
C0008070 (UMLS CUI [1,2])
C2185951 (UMLS CUI [2,1])
C0730005 (UMLS CUI [2,2])
C2185951 (UMLS CUI [3,1])
C0036375 (UMLS CUI [3,2])
C2185951 (UMLS CUI [4,1])
C0681383 (UMLS CUI [4,2])
Amount of hours
Item
How many hours?
integer
C0439227 (UMLS CUI [1,1])
C1265611 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
Assistance needed by nurse, babysitter or any type of paid caregiver
Item
Did you request assistance from a nurse, a babysitter or any type of paid caregiver to look after your child during this illness?
boolean
C3840284 (UMLS CUI [1,1])
C0028661 (UMLS CUI [1,2])
C3840284 (UMLS CUI [2,1])
C0337606 (UMLS CUI [2,2])
C3840284 (UMLS CUI [3,1])
C0085537 (UMLS CUI [3,2])
Amount of hours
Item
How many hours?
integer
C0439227 (UMLS CUI [1,1])
C1265611 (UMLS CUI [1,2])
C0085537 (UMLS CUI [1,3])
Parents seeking medical advice for illness
Item
If your child were not participating in this trial, would you, as parents / guardians, have contacted or visited a physician to seek medical advice for this illness?
boolean
C1386497 (UMLS CUI [1,1])
C0030551 (UMLS CUI [1,2])
C2348568 (UMLS CUI [1,3])
Item Group
Pain
C0030193 (UMLS CUI-1)
back or abdominal pain varicella or zoster
Item
Did the child present any back or abdominal pain during this illness?
boolean
C0004604 (UMLS CUI [1,1])
C0008049 (UMLS CUI [1,2])
C0740380 (UMLS CUI [1,3])
C0000737 (UMLS CUI [2,1])
C0008049 (UMLS CUI [2,2])
C0740380 (UMLS CUI [2,3])
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