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Clinical Data Review Form GSK Ropinirole Restless Legs Syndrome 101468

1 Formulär  
Instructions: Attach a completed Clinical Data Review Form to CRF module sent to Data Management. Use the form to record/clarify and inconsistencies. N.B. The form should remain with the working copy of the CRF modules at all times.
Beskrivning

Instructions: Attach a completed Clinical Data Review Form to CRF module sent to Data Management. Use the form to record/clarify and inconsistencies. N.B. The form should remain with the working copy of the CRF modules at all times.

Alias
UMLS CUI-1
C1442085
To: Data Management @
Beskrivning

Recipient

Datatyp

text

Alias
UMLS CUI [1]
C1709854
Drug ID
Beskrivning

Drug Name

Datatyp

text

Alias
UMLS CUI [1]
C2360065
Protocol No.:
Beskrivning

Protocol Number

Datatyp

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C1518419
Inv. Name/Centre No:
Beskrivning

Centre Number

Datatyp

text

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0019994
Patient No:
Beskrivning

Patient Number

Datatyp

text

Alias
UMLS CUI [1]
C1830427
Form: Medical Dept. @
Beskrivning

Sender

Datatyp

text

Alias
UMLS CUI [1]
C1553421
CRF Module(s):
Beskrivning

CRF Module

Datatyp

text

Alias
UMLS CUI [1,1]
C1516308
UMLS CUI [1,2]
C1709061
Other Data (questionnaires, diary, cards, etc.)
Beskrivning

Other Data

Datatyp

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C1511726
Review comments (if more space is needed for any of the following sections, add to Section 6 'Other Comments' below)
Beskrivning

Review comments (if more space is needed for any of the following sections, add to Section 6 'Other Comments' below)

Alias
UMLS CUI-1
C0282443
UMLS CUI-2
C0947611
1) Serious AE
Beskrivning

Serious Adverse Event

Datatyp

boolean

Alias
UMLS CUI [1]
C1519255
1) Serious AE: If 'YES', AE Text:
Beskrivning

Serious Adverse Event: Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C2348235
2) Missing pages:
Beskrivning

Missing pages

Datatyp

boolean

Alias
UMLS CUI [1]
C1548329
2) Missing pages If 'YES', to follow:
Beskrivning

Missing pages: Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C1548329
UMLS CUI [1,2]
C2348235
3) Missing data
Beskrivning

Missing data

Datatyp

boolean

Alias
UMLS CUI [1]
C0814891
3) Missing data Page No:
Beskrivning

Missing data: Page Number

Datatyp

text

Alias
UMLS CUI [1,1]
C0814891
UMLS CUI [1,2]
C1704732
3) Missing data If 'YES', to follow:
Beskrivning

Missing data: Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C0814891
UMLS CUI [1,2]
C2348235
3) Missing data If 'YES', unobtainable:
Beskrivning

Missing data: Unobtainable

Datatyp

text

Alias
UMLS CUI [1]
C2046401
4) Protocol Violations:
Beskrivning

Protocol Violation

Datatyp

boolean

Alias
UMLS CUI [1]
C1709750
4) Protocol Violation If 'YES', Page No:
Beskrivning

Protocol Violation: Page Number

Datatyp

text

Alias
UMLS CUI [1,1]
C1709750
UMLS CUI [1,2]
C1704732
4) Protocol Violations If 'YES', specify:
Beskrivning

Protocol Violation: Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C1709750
UMLS CUI [1,2]
C2348235
5) DRQ replies:
Beskrivning

DRQ reply

Datatyp

text

6) Other comments:
Beskrivning

Comment

Datatyp

boolean

Alias
UMLS CUI [1]
C0947611
6) Other comments: If 'YES', Page No:
Beskrivning

Comment: Page Number

Datatyp

text

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1704732
6) Other comments: If 'YES', specify:
Beskrivning

Comment: Specification

Datatyp

text

Alias
UMLS CUI [1]
C2348235
Name
Beskrivning

Investigator's Name

Datatyp

text

Alias
UMLS CUI [1]
C2826892
Date of review:
Beskrivning

Date of review

Datatyp

date

Måttenheter
  • dd-mmm-yyyy
dd-mmm-yyyy
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Similar models

Clinical Data Review Form GSK Ropinirole Restless Legs Syndrome 101468

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Instructions: Attach a completed Clinical Data Review Form to CRF module sent to Data Management. Use the form to record/clarify and inconsistencies. N.B. The form should remain with the working copy of the CRF modules at all times.
C1442085 (UMLS CUI-1)
Recipient
Item
To: Data Management @
text
C1709854 (UMLS CUI [1])
Drug Name
Item
Drug ID
text
C2360065 (UMLS CUI [1])
Protocol Number
Item
Protocol No.:
text
C3274381 (UMLS CUI [1,1])
C1518419 (UMLS CUI [1,2])
Centre Number
Item
Inv. Name/Centre No:
text
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Patient Number
Item
Patient No:
text
C1830427 (UMLS CUI [1])
Sender
Item
Form: Medical Dept. @
text
C1553421 (UMLS CUI [1])
CRF Module
Item
CRF Module(s):
text
C1516308 (UMLS CUI [1,1])
C1709061 (UMLS CUI [1,2])
Other Data
Item
Other Data (questionnaires, diary, cards, etc.)
text
C0205394 (UMLS CUI [1,1])
C1511726 (UMLS CUI [1,2])
Item Group
Review comments (if more space is needed for any of the following sections, add to Section 6 'Other Comments' below)
C0282443 (UMLS CUI-1)
C0947611 (UMLS CUI-2)
Serious Adverse Event
Item
1) Serious AE
boolean
C1519255 (UMLS CUI [1])
Serious Adverse Event: Specification
Item
1) Serious AE: If 'YES', AE Text:
text
C1519255 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Missing pages
Item
2) Missing pages:
boolean
C1548329 (UMLS CUI [1])
Missing pages: Specification
Item
2) Missing pages If 'YES', to follow:
text
C1548329 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Missing data
Item
3) Missing data
boolean
C0814891 (UMLS CUI [1])
Missing data: Page Number
Item
3) Missing data Page No:
text
C0814891 (UMLS CUI [1,1])
C1704732 (UMLS CUI [1,2])
Missing data: Specification
Item
3) Missing data If 'YES', to follow:
text
C0814891 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Missing data: Unobtainable
Item
3) Missing data If 'YES', unobtainable:
text
C2046401 (UMLS CUI [1])
Protocol Violation
Item
4) Protocol Violations:
boolean
C1709750 (UMLS CUI [1])
Protocol Violation: Page Number
Item
4) Protocol Violation If 'YES', Page No:
text
C1709750 (UMLS CUI [1,1])
C1704732 (UMLS CUI [1,2])
Protocol Violation: Specification
Item
4) Protocol Violations If 'YES', specify:
text
C1709750 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
DRQ reply
Item
5) DRQ replies:
text
Comment
Item
6) Other comments:
boolean
C0947611 (UMLS CUI [1])
Comment: Page Number
Item
6) Other comments: If 'YES', Page No:
text
C0947611 (UMLS CUI [1,1])
C1704732 (UMLS CUI [1,2])
Comment: Specification
Item
6) Other comments: If 'YES', specify:
text
C2348235 (UMLS CUI [1])
Investigator's Name
Item
Name
text
C2826892 (UMLS CUI [1])
Date of review
Item
Date of review:
date
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