English

GSK Ropinirole in Subjects with Restless Legs Syndrome 101468/191 Form D (Form 23)

1 forms  
General Information
Description

General Information

Center Number
Description

Center Number

Data type

integer

Patient No
Description

patient number

Data type

integer

Patient Initials
Description

Patient Initials

Data type

text

Form D
Description

Form D

Certified cause of death
Description

Certified cause of death

Data type

text

Date of death
Description

Date of death

Data type

date

Was a post-mortem carried out?
Description

Post-mortem

Data type

text

If post-mortem was carried out, please summarize findings (include diagnosis)
Description

Post-mortem findings

Data type

text

Reporting Physician´s Signature
Description

Reporting Physician´s Signature

Data type

text

Date
Description

Date

Data type

date

Back to the top of the page

Similar models

GSK Ropinirole in Subjects with Restless Legs Syndrome 101468/191 Form D (Form 23)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
General Information
Center Number
Item
Center Number
integer
patient number
Item
Patient No
integer
Patient Initials
Item
Patient Initials
text
Item Group
Form D
Certified cause of death
Item
Certified cause of death
text
Date of death
Item
Date of death
date
Item
Was a post-mortem carried out?
text
Post-mortem
Code List
Was a post-mortem carried out?
CL Item
No (1)
CL Item
Yes -> If "Yes" please summarize findings (including diagnosis) below (2)
Post-mortem findings
Item
If post-mortem was carried out, please summarize findings (include diagnosis)
text
Reporting Physician´s Signature
Item
Reporting Physician´s Signature
text
Date
Item
Date
date
Back to the top of the page