ID

25685

Beskrivning

Visit 5 - GSK Study: Hepatitis A & B Vaccine vs. monovalent Hep. A and Hep. B vaccines and risk factors likely to influence their immunogenicity NCT00289731 Study ID: 100382 Clinical Study ID: 100382 Study Title: Evaluate the Effect of Several Risk Factors That Are Likely to Influence the Immunogenicity of GSK Biologicals’ Combined Hepatitis A & B Vaccine, vs Separately Administered Monovalent Hepatitis A and Hepatitis B Vaccines Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00289731 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 4 Study Recruitment Status: Completed Generic Name: Hepatitis A (Inactivated), Hepatitis B (Recombinant) Vaccine Trade Name: Twinrix Study Indication: Hepatitis A; Hepatitis B

Nyckelord

Versioner (1)
  1. 2017-09-09 2017-09-09 -
Rättsinnehavare

glaxoSmithKline

Uppladdad den

9 september 2017

DOI

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Licens

Creative Commons BY-NC 3.0
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Visit 5 - GSK Study: Hepatitis A & B Vaccine vs. monovalent Hep. A and Hep. B vaccines and risk factors likely to influence their immunogenicity NCT00289731

Engelsk

Visit 5 - GSK Study: Hepatitis A & B Vaccine vs. monovalent Hep. A and Hep. B vaccines and risk factors likely to influence their immunogenicity NCT00289731

1 Formulär  
Informed consent
Beskrivning

Informed consent

Alias
UMLS CUI-1
C0021430
Informed Consent Date
Beskrivning

I certify that Informed Consent has been obtained prior to any study procedure.

Datatyp

date

Alias
UMLS CUI [1]
C2985782
Demographics
Beskrivning

Demographics

Alias
UMLS CUI-1
C0011298
Date of Birth
Beskrivning

Date of Birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Gender
Beskrivning

Gender

Datatyp

text

Alias
UMLS CUI [1]
C0079399
Race
Beskrivning

Race

Datatyp

integer

Alias
UMLS CUI [1]
C0034510
Other Race, please specify
Beskrivning

If you chose 'Other Race', please specify

Datatyp

text

Alias
UMLS CUI [1,1]
C0034510
UMLS CUI [1,2]
C0205394
UMLS CUI [1,3]
C3845569
Laboratory tests
Beskrivning

Laboratory tests

Alias
UMLS CUI-1
C0022885
Has a blood sample been taken for testing anti-HAV and anti-HBs antibodies?
Beskrivning

Blood sample

Datatyp

boolean

Alias
UMLS CUI [1]
C0005834
Date blood sample taken
Beskrivning

Please complete only if different from visit date

Datatyp

date

Alias
UMLS CUI [1,1]
C1277698
UMLS CUI [1,2]
C0011008
Has the subject suffered from hepatitis A or B infection since the last study contact?
Beskrivning

Hepatitis A or hepatitis B

Datatyp

boolean

Alias
UMLS CUI [1]
C0019159
UMLS CUI [2]
C0019163
Follow-up- Studies
Beskrivning

Follow-up- Studies

Alias
UMLS CUI-1
C0016441
UMLS CUI-2
C0042210
Would the subject be willing to participate in a follow-up study?
Beskrivning

If "No", please specify the most appropriate reason.

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0016441
UMLS CUI [1,2]
C2348568
Please specify the most appropriate reason.
Beskrivning

Reason for non participation in follow-up

Datatyp

integer

Alias
UMLS CUI [1,1]
C0016441
UMLS CUI [1,2]
C2348568
UMLS CUI [1,3]
C0566251
Please specify Adverse Events, or Serious Adverse Events.
Beskrivning

specify Adverse Events

Datatyp

text

Alias
UMLS CUI [1,1]
C0559546
UMLS CUI [1,2]
C1521902
UMLS CUI [2,1]
C1519255
UMLS CUI [2,2]
C1521902
Specify other reason
Beskrivning

Other reason for no follow-up

Datatyp

text

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C3840932
UMLS CUI [1,3]
C1521902
Investigator's signature
Beskrivning

Investigator's signature

Alias
UMLS CUI-1
C2346576
Investigator's signature
Beskrivning

I confirm that I have reviewed the data in this Case Report Form for this subject. All information entered by myself or my colleagues is, to the best of my knowledge, complete and accurate, as of the date below.

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Printed Investigator's name
Beskrivning

Printed Investigator's name

Datatyp

text

Alias
UMLS CUI [1]
C2826892
Date
Beskrivning

Date of investigator's signature

Datatyp

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Reason for non participation
Beskrivning

Reason for non participation

Alias
UMLS CUI-1
C0558080
UMLS CUI-2
C0679823
UMLS CUI-3
C0392360
Subject number
Beskrivning

Subject number

Datatyp

text

Alias
UMLS CUI [1]
C2348585
Date of Birth
Beskrivning

Date of Birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Reason for non participation
Beskrivning

Reason for non participation

Datatyp

integer

Alias
UMLS CUI [1,1]
C0558080
UMLS CUI [1,2]
C0679823
UMLS CUI [1,3]
C0392360
Please specify criteria for non-eligibility.
Beskrivning

Subject not eligible? - please specify criteria that are not fullfilled:

Datatyp

text

Alias
UMLS CUI [1,1]
C1555471
UMLS CUI [1,2]
C1521902
Subject eligible but not willing to participate due to: Please specify:
Beskrivning

Only fill in, if you chose "Subject eligible but not willing to participate due to: Please specify:" before.

Datatyp

text

Alias
UMLS CUI [1,1]
C3846156
UMLS CUI [1,2]
C0392360
Please specify serious adverse event which is the reason for the subject being not willing to participate
Beskrivning

Only fill in, if you chose "adverse events, or serious adverse event: please specify" before.

Datatyp

text

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C1519255
UMLS CUI [1,3]
C1521902
Please specify other reason for subject not willing to participate
Beskrivning

Only fill in if you chose "other" before.

Datatyp

text

Alias
UMLS CUI [1,1]
C3840932
UMLS CUI [1,2]
C1521902
UMLS CUI [1,3]
C2348568
Date of death
Beskrivning

Only fill in, if you chose "Subject died on:" before.

Datatyp

date

Alias
UMLS CUI [1]
C1148348
Date of contact
Beskrivning

Date of contact

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1705415
UMLS CUI [1,3]
C2348568
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Similar models

Visit 5 - GSK Study: Hepatitis A & B Vaccine vs. monovalent Hep. A and Hep. B vaccines and risk factors likely to influence their immunogenicity NCT00289731

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Informed consent
C0021430 (UMLS CUI-1)
Informed Consent Date
Item
Informed Consent Date
date
C2985782 (UMLS CUI [1])
Item Group
Demographics
C0011298 (UMLS CUI-1)
Date of Birth
Item
Date of Birth
date
C0421451 (UMLS CUI [1])
Item
Gender
text
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
Male (M)
CL Item
Female (F)
Item
Race
integer
C0034510 (UMLS CUI [1])
Race
Code List
Race
CL Item
Black (1)
CL Item
Arabic/North African (4)
CL Item
White/Caucasian (2)
CL Item
East & South East Asian (5)
CL Item
South Asian (6)
CL Item
Other (9)
Other Race
Item
Other Race, please specify
text
C0034510 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C3845569 (UMLS CUI [1,3])
Item Group
Laboratory tests
C0022885 (UMLS CUI-1)
Blood sample
Item
Has a blood sample been taken for testing anti-HAV and anti-HBs antibodies?
boolean
C0005834 (UMLS CUI [1])
Date blood sample taken
Item
Date blood sample taken
date
C1277698 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Hepatitis A or hepatitis B
Item
Has the subject suffered from hepatitis A or B infection since the last study contact?
boolean
C0019159 (UMLS CUI [1])
C0019163 (UMLS CUI [2])
Item Group
Follow-up- Studies
C0016441 (UMLS CUI-1)
C0042210 (UMLS CUI-2)
willing to participate in a follow-up study
Item
Would the subject be willing to participate in a follow-up study?
boolean
C0016441 (UMLS CUI [1,1])
C2348568 (UMLS CUI [1,2])
Item
Please specify the most appropriate reason.
integer
C0016441 (UMLS CUI [1,1])
C2348568 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
Reason for non participation in follow-up
Code List
Please specify the most appropriate reason.
CL Item
Adverse Events, or Serious Adverse Events (1)
CL Item
Others (2)
specify Adverse Events
Item
Please specify Adverse Events, or Serious Adverse Events.
text
C0559546 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
C1519255 (UMLS CUI [2,1])
C1521902 (UMLS CUI [2,2])
Other reason for no follow-up
Item
Specify other reason
text
C2348568 (UMLS CUI [1,1])
C3840932 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item Group
Investigator's signature
C2346576 (UMLS CUI-1)
Investigator's signature
Item
Investigator's signature
text
C2346576 (UMLS CUI [1])
Printed Investigator's name
Item
Printed Investigator's name
text
C2826892 (UMLS CUI [1])
Date of investigator's signature
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
Reason for non participation
C0558080 (UMLS CUI-1)
C0679823 (UMLS CUI-2)
C0392360 (UMLS CUI-3)
Subject number
Item
Subject number
text
C2348585 (UMLS CUI [1])
Date of Birth
Item
Date of Birth
date
C0421451 (UMLS CUI [1])
Item
Reason for non participation
integer
C0558080 (UMLS CUI [1,1])
C0679823 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Reason for non participation
Code List
Reason for non participation
CL Item
Subject not eligible? - please specify criteria that are not fulfilled: (1)
CL Item
Subject lost to follow-up or not reached (2)
CL Item
Subject eligible but not willing to participate due to: (3)
CL Item
Subject died on: (4)
specify criteria non eligible
Item
Please specify criteria for non-eligibility.
text
C1555471 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
not willing to participate
Item
Subject eligible but not willing to participate due to: Please specify:
text
C3846156 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
specify serious adverse event
Item
Please specify serious adverse event which is the reason for the subject being not willing to participate
text
C2348568 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
specify other reason
Item
Please specify other reason for subject not willing to participate
text
C3840932 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
C2348568 (UMLS CUI [1,3])
Date of death
Item
Date of death
date
C1148348 (UMLS CUI [1])
Date of contact
Item
Date of contact
date
C0011008 (UMLS CUI [1,1])
C1705415 (UMLS CUI [1,2])
C2348568 (UMLS CUI [1,3])
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