ID

25887

Beschreibung

Study ID: 100551 (EXT Y11) Clinical Study ID: 100551 Study Title: A double blind randomised, comparative study of the immunogenicity and reactogenicity of three different lots of GlaxoSmithKline Biologicals’ combined hepatitis A - hepatitis B vaccine when administered in healthy adults Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00289770 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: Hepatitis A (Inactivated), Hepatitis B (Recombinant) Vaccine Trade Name: Twinrix Study Indication: Hepatitis A; Hepatitis B

Stichworte

  1. 23.06.17 23.06.17 -
  2. 25.09.17 25.09.17 -
Hochgeladen am

25. September 2017

DOI

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Comparative study of the immunogenicity and reactogenicity of three different lots of GlaxoSmithKline Biologicals’ combined hepatitis A - hepatitis B (Visit 22 Year 15)

Comparative study of the immunogenicity and reactogenicity of three different lots of GlaxoSmithKline Biologicals’ combined hepatitis A - hepatitis B (Visit 22 Year 15)

Form information
Beschreibung

Form information

Alias
UMLS CUI-1
C1533716
Information
Beschreibung

REMINDERS ADVERSE EVENTS Please report adverse events as specified in the Protocol and fill in the Non-Serious Adverse Events section or the Serious Adverse Event (SAE) form, as appropriate. This SAE form must be faxed to GlaxoSmithKline within 24 hours of you becoming aware of these events. MEDICATION Please report medication as specified in the Protocol and fill in the Medication section. Please report concomitant vaccination in the Concomitant Vaccination section. PREGNANCY In case of pregnancy please fill in the Pregnancy Notification form. This form must be faxed to GlaxoSmithKline within 24 hours of you becoming aware of these events. CONTRAINDICATIONS Before any vaccine administration, please review the Contraindications as specified in the Protocol. DIARY CARD Please provide the diary card to the subject.

Datentyp

text

Alias
UMLS CUI [1]
C1533716
General medical history / physical examination
Beschreibung

General medical history / physical examination

Alias
UMLS CUI-1
C0262926
UMLS CUI-3
C0031809
Date of visit
Beschreibung

Date of visit

Datentyp

date

Alias
UMLS CUI [1]
C1320303
Subject number
Beschreibung

Subject number

Datentyp

integer

Alias
UMLS CUI [1]
C2348585
Are you aware of any pre-existing conditions or or signs and/or symptoms present in the subject prior to the start of the study?
Beschreibung

pre-existing conditions

Datentyp

text

Alias
UMLS CUI [1]
C0521987
Cutaneous
Beschreibung

Cutaneous

Datentyp

text

Alias
UMLS CUI [1]
C0221912
Cutaneous: diagnosis
Beschreibung

Cutaneous: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0037274
UMLS CUI [1,2]
C0011900
Eyes
Beschreibung

Eyes

Datentyp

text

Alias
UMLS CUI [1]
C0015392
Eyes: diagnosis
Beschreibung

Eyes: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0015397
UMLS CUI [1,2]
C0011900
Ears-Nose-Throat
Beschreibung

Ears-Nose-Throat

Datentyp

text

Alias
UMLS CUI [1]
C0395797
Ears-Nose-Throat: diagnosis
Beschreibung

Ears-Nose-Throat: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0395797
UMLS CUI [1,2]
C0011900
Cardiovascular
Beschreibung

Cardiovascular

Datentyp

text

Alias
UMLS CUI [1]
C0007226
Cardiovascular: diagnosis
Beschreibung

Cardiovascular: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0007222
UMLS CUI [1,2]
C0011900
Respiratory
Beschreibung

Respiratory

Datentyp

text

Alias
UMLS CUI [1]
C0035237
Respiratory: diagnosis
Beschreibung

Respiratory: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0035204
UMLS CUI [1,2]
C0011900
Gastrointestinal
Beschreibung

Gastrointestinal

Datentyp

text

Alias
UMLS CUI [1]
C0012240
Gastrointestinal: diagnosis
Beschreibung

Gastrointestinal: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0017178
UMLS CUI [1,2]
C0011900
Muskuloskeletal
Beschreibung

Muskuloskeletal

Datentyp

text

Alias
UMLS CUI [1]
C0026860
Muskuloskeletal: diagnosis
Beschreibung

Muskuloskeletal: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0026857
UMLS CUI [1,2]
C0011900
Neurological
Beschreibung

Neurological

Datentyp

text

Alias
UMLS CUI [1]
C0027763
Neurological: diagnosis
Beschreibung

Neurological: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0027765
UMLS CUI [1,2]
C0011900
Genitourinary
Beschreibung

Genitourinary

Datentyp

text

Alias
UMLS CUI [1]
C0042066
Genitourinary: diagnosis
Beschreibung

Genitourinary: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0080276
UMLS CUI [1,2]
C0011900
Haematology
Beschreibung

Haematology

Datentyp

text

Alias
UMLS CUI [1]
C0474523
Haematology: diagnosis
Beschreibung

Haematology: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0018939
UMLS CUI [1,2]
C0011900
Allergies
Beschreibung

Allergies

Datentyp

text

Alias
UMLS CUI [1]
C0020517
Allergies: diagnosis
Beschreibung

Allergies: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0020517
UMLS CUI [1,2]
C0011900
Endocrine
Beschreibung

Endocrine

Datentyp

text

Alias
UMLS CUI [1]
C0014130
Endocrine: diagnosis
Beschreibung

Endocrine: diagnosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0014130
UMLS CUI [1,2]
C0011900
Other (specify)
Beschreibung

Other (specify)

Datentyp

text

Alias
UMLS CUI [1]
C3845569
Other
Beschreibung

Other

Datentyp

text

Alias
UMLS CUI [1]
C0205394
Laboratory tests
Beschreibung

Laboratory tests

Alias
UMLS CUI-1
C0022885
Has a blood sample been taken?
Beschreibung

Blood sample

Datentyp

text

Alias
UMLS CUI [1]
C0005834
Date of blood sample
Beschreibung

Date of blood sample

Datentyp

date

Alias
UMLS CUI [1]
C1317250
Has a urine sample been taken?
Beschreibung

HCG urine pregnancy test

Datentyp

text

Alias
UMLS CUI [1]
C0430056
Date of pregnancy test
Beschreibung

Date of pregnancy test

Datentyp

date

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0011008
Result from pregnancy test
Beschreibung

Result from pregnancy test

Datentyp

text

Alias
UMLS CUI [1]
C0427777
Vaccine administration
Beschreibung

Vaccine administration

Alias
UMLS CUI-1
C2368628
Date of vaccine administration
Beschreibung

Date of vaccine administration

Datentyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2368628
Pre-vaccination temperature
Beschreibung

Pre-vaccination temperature

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C0042196
°C
Route
Beschreibung

Route

Datentyp

text

Vaccacine administration
Beschreibung

only one box must be ticked by vaccine

Datentyp

text

Twinrix™ Adult (720/20) Vaccine: Has the study vaccine been administered according to the Protocol?
Beschreibung

Twinrix™ Adult (720/20) Vaccine: Protocol Administration

Datentyp

text

Alias
UMLS CUI [1,1]
C0595042
UMLS CUI [1,2]
C0547696
Twinrix™ Adult (720/20) Vaccine: specification of not administered according to the protocol
Beschreibung

Twinrix™ Adult (720/20) Vaccine: Protocol Administration Specification

Datentyp

text

Alias
UMLS CUI [1,1]
C0595042
UMLS CUI [1,2]
C0547696
UMLS CUI [1,3]
C2348235
Engerix™ (20 μg) Vaccine: specification of not administered according to the protocol
Beschreibung

Engerix™ (20 μg) Vaccine: Protocol Administration Specification

Datentyp

text

Alias
UMLS CUI [1,1]
C0116078
UMLS CUI [1,2]
C0547696
UMLS CUI [1,3]
C2348235
Havrix™ (720 EL.U)Vaccine: specification of not administered according to the protocol
Beschreibung

Havrix™ (720 EL.U)Vaccine: Protocol Administration Specification

Datentyp

text

Alias
UMLS CUI [1,1]
C0700881
UMLS CUI [1,2]
C0547696
UMLS CUI [1,3]
C2348235
Why not administered?
Beschreibung

Please tick the ONE most appropriate category for non administration

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C2348235
Other, please specify (reason for non administration)
Beschreibung

Specification of reason for non administration

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C0566251
Please tick who took the decision
Beschreibung

IMMEDIATE POST-VACCINATION OBSERVATION If any adverse events occurred during the immediate post-vaccination time (30 minutes) please fill in the Solicited Adverse Events section, the Non-Serious Adverse Event section or a Serious Adverse Event form. If any prophylactic medication has been administered in anticipation of study vaccine reaction, please complete the Medication section and tick prophylactic box. Any other vaccines administered during the study period must be recorded in the Concomitant Vaccination section.

Datentyp

text

Alias
UMLS CUI [1,1]
C0679006
UMLS CUI [1,2]
C2368628
Unsolicited adverse events
Beschreibung

Unsolicited adverse events

Alias
UMLS CUI-1
C0877248
UMLS CUI-2
C0042196
Has the subject experienced any serious or non-serious unsolicited adverse events within one month post-vaccination?
Beschreibung

Unsolicited adverse events

Datentyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0042196
Soliticited adverse events - local symptoms
Beschreibung

Soliticited adverse events - local symptoms

Alias
UMLS CUI-1
C0877248
UMLS CUI-2
C1457887
UMLS CUI-3
C0205276
Has the subject experienced any of the following sings/symptoms at the administration site during the solicited period?
Beschreibung

Soliticited adverse events - local symptoms

Datentyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C1457887
Local symptoms: Redness
Beschreibung

Erythema

Datentyp

text

Alias
UMLS CUI [1]
C0041834
Local symptoms day 0
Beschreibung

Erythema: day 0

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0041834
UMLS CUI [1,2]
C0808070
mm
Local symptoms day 1
Beschreibung

Erythema: day 1

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0041834
UMLS CUI [1,2]
C1442449
mm
Local symptoms day 2
Beschreibung

Erythema: day 2

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0041834
UMLS CUI [1,2]
C3842676
mm
Local symptoms day 3
Beschreibung

Erythema: day 3

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0041834
UMLS CUI [1,2]
C3842675
mm
Ongoing after Day 3
Beschreibung

Erythema: Ongoing

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0041834
UMLS CUI [1,2]
C0549178
Date of last day of symptoms (redness)
Beschreibung

Erythema: Date of last day of symptoms

Datentyp

date

Alias
UMLS CUI [1,1]
C0041834
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1517741
UMLS CUI [1,4]
C1457887
Local symptoms: swelling
Beschreibung

Swelling

Datentyp

text

Alias
UMLS CUI [1]
C0038999
Local symptoms day 0
Beschreibung

Swelling: day 0

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0038999
UMLS CUI [1,2]
C0808070
mm
Local symptoms day 1
Beschreibung

Swelling: day 1

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0038999
UMLS CUI [1,2]
C1442449
mm
Local symptoms day 2
Beschreibung

Swelling: day 2

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0038999
UMLS CUI [1,2]
C3842676
mm
Local symptoms day 3
Beschreibung

Swelling: day 3

Datentyp

float

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0038999
UMLS CUI [1,2]
C3842675
mm
Ongoing after Day 3
Beschreibung

Swelling: Ongoing after Day 3

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0038999
UMLS CUI [1,2]
C0549178
Date of last day of symptoms (swelling)
Beschreibung

Swelling: Date of last day of symptoms

Datentyp

date

Alias
UMLS CUI [1,1]
C0038999
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1517741
UMLS CUI [1,4]
C1457887
Local symptoms: pain
Beschreibung

Intensity of pain

Datentyp

text

Alias
UMLS CUI [1]
C1320357
Intensity of pain day 0
Beschreibung

Intensity of pain: day 0

Datentyp

text

Alias
UMLS CUI [1,1]
C1320357
UMLS CUI [1,2]
C0808070
Intensity of pain day 1
Beschreibung

Intensity of pain: day 1

Datentyp

text

Alias
UMLS CUI [1,1]
C1320357
UMLS CUI [1,2]
C1442449
Intensity of pain day 2
Beschreibung

Intensity of pain: day 2

Datentyp

text

Alias
UMLS CUI [1,1]
C1320357
UMLS CUI [1,2]
C3842676
Intensity of pain day 3
Beschreibung

Intensity of pain: day 3

Datentyp

text

Alias
UMLS CUI [1,1]
C1320357
UMLS CUI [1,2]
C3842675
Ongoing after Day 3
Beschreibung

Intensity of pain: Ongoing after Day 3

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1320357
UMLS CUI [1,2]
C0549178
Date of last day of symptoms (pain)
Beschreibung

Intensity of pain: Date of last day of symptoms

Datentyp

date

Alias
UMLS CUI [1,1]
C1320357
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1517741
UMLS CUI [1,4]
C1457887
Solicid adverse events - general symptoms
Beschreibung

Solicid adverse events - general symptoms

Alias
UMLS CUI-1
C0877248
UMLS CUI-2
C0159028
Has the subject experienced any of the following signs/symptoms during the solicited period?
Beschreibung

Soliticed adverse events: General symptom

Datentyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0159028
General symptoms: Fever
Beschreibung

Fever

Datentyp

boolean

Alias
UMLS CUI [1]
C0015967
Fever: if yes, please specify amount of fever
Beschreibung

Body Temperature

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1]
C0005903
°C
Taking temperature
Beschreibung

Temperature measuring method

Datentyp

text

Alias
UMLS CUI [1]
C0886414
Fever day 0
Beschreibung

Fever: day 0

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C0808070
°C
Fever not taken day 0
Beschreibung

Fever: Day 0 Specification

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C0808070
UMLS CUI [1,3]
C2348235
Fever day 1
Beschreibung

Fever: day 1

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C1442449
°C
Fever not taken day 1
Beschreibung

Fever: Day 1 Specification

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C1442449
UMLS CUI [1,3]
C2348235
Fever day 2
Beschreibung

Fever: day 2

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C3842676
°C
Fever not taken day 2
Beschreibung

Fever: Day 2 Specification

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C3842676
UMLS CUI [1,3]
C2348235
Fever day 3
Beschreibung

Fever: day 3

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C3842675
°C
Fever not taken day 3
Beschreibung

Fever: Day 3 Specification

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C3842675
UMLS CUI [1,3]
C2348235
Ongoing after Day 3
Beschreibung

Fever: Ongoing after Day 3

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C0549178
Date of last Day of Symptoms
Beschreibung

Fever: Date of last Day of Symptoms

Datentyp

date

Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1517741
UMLS CUI [1,4]
C1457887
Causality
Beschreibung

Fever: Causality

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015967
UMLS CUI [1,2]
C0015127
Fatigue
Beschreibung

Fatigue

Datentyp

text

Alias
UMLS CUI [1]
C0015672
Intensity fatigue day 0
Beschreibung

Fatigue: day 0

Datentyp

text

Alias
UMLS CUI [1,1]
C0015672
UMLS CUI [1,2]
C0808070
Intensity fatigue day 1
Beschreibung

Fatigue: day 1

Datentyp

text

Alias
UMLS CUI [1,1]
C0015672
UMLS CUI [1,2]
C1442449
Intensity fatigue day 2
Beschreibung

Fatigue: day 2

Datentyp

text

Alias
UMLS CUI [1,1]
C0015672
UMLS CUI [1,2]
C3842676
Intensity fatigue day 3
Beschreibung

Fatigue: day 3

Datentyp

text

Alias
UMLS CUI [1,1]
C0015672
UMLS CUI [1,2]
C3842675
Ongoing after Day 3
Beschreibung

Fatigue: Ongoing after Day 3

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015672
UMLS CUI [1,2]
C0549178
Date of last Day of symptoms
Beschreibung

Fatigue: Date of last Day of symptoms

Datentyp

date

Alias
UMLS CUI [1,1]
C0015672
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1517741
UMLS CUI [1,4]
C1457887
Causality?
Beschreibung

Fatigue: Causality?

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015672
UMLS CUI [1,2]
C0015127
Headache
Beschreibung

Headache

Datentyp

text

Alias
UMLS CUI [1]
C0018681
Intensity headache day 0
Beschreibung

Headache: day 0

Datentyp

text

Alias
UMLS CUI [1,1]
C0018681
UMLS CUI [1,2]
C0808070
Intensity headache day 1
Beschreibung

Headache: day 1

Datentyp

text

Alias
UMLS CUI [1,1]
C0018681
UMLS CUI [1,2]
C1442449
Intensity headache day 2
Beschreibung

Headache: day 2

Datentyp

text

Alias
UMLS CUI [1,1]
C0018681
UMLS CUI [1,2]
C3842676
Intensity headache day 3
Beschreibung

Headache: day 3

Datentyp

text

Alias
UMLS CUI [1,1]
C0018681
UMLS CUI [1,2]
C3842675
Ongoing after Day 3
Beschreibung

Headache: Ongoing after Day 3

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0018681
UMLS CUI [1,2]
C0549178
Date of last Day of Symptoms
Beschreibung

Headache: Date of last Day of Symptoms

Datentyp

date

Alias
UMLS CUI [1,1]
C0018681
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1517741
UMLS CUI [1,4]
C1457887
Causality
Beschreibung

Headache: Causality

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0018681
UMLS CUI [1,2]
C0015127
Gastrointestinal symptoms
Beschreibung

Gastrointestinal symptoms

Datentyp

text

Alias
UMLS CUI [1]
C0426576
Intensity gastrointestinal symptoms day 0
Beschreibung

Gastrointestinal symptoms: day 0

Datentyp

text

Alias
UMLS CUI [1,1]
C0426576
UMLS CUI [1,2]
C0808070
Intensity gastrointestinal symptoms day 1
Beschreibung

Gastrointestinal symptoms: day 1

Datentyp

text

Alias
UMLS CUI [1,1]
C0426576
UMLS CUI [1,2]
C1442449
Intensity gastrointestinal symptoms day 2
Beschreibung

Gastrointestinal symptoms: day 2

Datentyp

text

Alias
UMLS CUI [1,1]
C0426576
UMLS CUI [1,2]
C3842676
Intensity gastrointestinal symptoms day 3
Beschreibung

Gastrointestinal symptoms: day 3

Datentyp

text

Alias
UMLS CUI [1,1]
C0426576
UMLS CUI [1,2]
C3842675
Ongoing after Day 3
Beschreibung

Gastrointestinal Symptoms: Ongoing after Day 3

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0426576
UMLS CUI [1,2]
C0549178
Date of last day of symptoms
Beschreibung

Gastrointestinal Symptoms: Date of last day of symptoms

Datentyp

date

Alias
UMLS CUI [1,1]
C0426576
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1517741
UMLS CUI [1,4]
C1457887
Causality
Beschreibung

Gastrointestinal Symptoms: Causality

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0426576
UMLS CUI [1,2]
C0015127

Ähnliche Modelle

Comparative study of the immunogenicity and reactogenicity of three different lots of GlaxoSmithKline Biologicals’ combined hepatitis A - hepatitis B (Visit 22 Year 15)

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Form information
C1533716 (UMLS CUI-1)
Information
Item
Information
text
C1533716 (UMLS CUI [1])
Item Group
General medical history / physical examination
C0262926 (UMLS CUI-1)
C0031809 (UMLS CUI-3)
Date of visit
Item
Date of visit
date
C1320303 (UMLS CUI [1])
Subject number
Item
Subject number
integer
C2348585 (UMLS CUI [1])
Item
Are you aware of any pre-existing conditions or or signs and/or symptoms present in the subject prior to the start of the study?
text
C0521987 (UMLS CUI [1])
Code List
Are you aware of any pre-existing conditions or or signs and/or symptoms present in the subject prior to the start of the study?
CL Item
No (1)
CL Item
Yes (Please choose appropriate box(es)and give diagnosis (2)
Item
Cutaneous
text
C0221912 (UMLS CUI [1])
Code List
Cutaneous
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Cutaneous: diagnosis
Item
Cutaneous: diagnosis
text
C0037274 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Eyes
text
C0015392 (UMLS CUI [1])
Code List
Eyes
CL Item
not appropriate  (1)
CL Item
past (2)
CL Item
current (3)
Eyes: diagnosis
Item
Eyes: diagnosis
text
C0015397 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Ears-Nose-Throat
text
C0395797 (UMLS CUI [1])
Code List
Ears-Nose-Throat
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Ears-Nose-Throat: diagnosis
Item
Ears-Nose-Throat: diagnosis
text
C0395797 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Cardiovascular
text
C0007226 (UMLS CUI [1])
Code List
Cardiovascular
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Cardiovascular: diagnosis
Item
Cardiovascular: diagnosis
text
C0007222 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Respiratory
text
C0035237 (UMLS CUI [1])
Code List
Respiratory
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Respiratory: diagnosis
Item
Respiratory: diagnosis
text
C0035204 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Gastrointestinal
text
C0012240 (UMLS CUI [1])
Code List
Gastrointestinal
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Gastrointestinal: diagnosis
Item
Gastrointestinal: diagnosis
text
C0017178 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Muskuloskeletal
text
C0026860 (UMLS CUI [1])
Code List
Muskuloskeletal
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Muskuloskeletal: diagnosis
Item
Muskuloskeletal: diagnosis
text
C0026857 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Neurological
text
C0027763 (UMLS CUI [1])
Code List
Neurological
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Neurological: diagnosis
Item
Neurological: diagnosis
text
C0027765 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Genitourinary
text
C0042066 (UMLS CUI [1])
Code List
Genitourinary
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Genitourinary: diagnosis
Item
Genitourinary: diagnosis
text
C0080276 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Haematology
text
C0474523 (UMLS CUI [1])
Code List
Haematology
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Haematology: diagnosis
Item
Haematology: diagnosis
text
C0018939 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Allergies
text
C0020517 (UMLS CUI [1])
Code List
Allergies
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Allergies: diagnosis
Item
Allergies: diagnosis
text
C0020517 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Endocrine
text
C0014130 (UMLS CUI [1])
Code List
Endocrine
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Endocrine: diagnosis
Item
Endocrine: diagnosis
text
C0014130 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Other (specify)
Item
Other (specify)
text
C3845569 (UMLS CUI [1])
Item
Other
text
C0205394 (UMLS CUI [1])
Code List
Other
CL Item
not appropriate (1)
CL Item
past (2)
CL Item
current (3)
Item Group
Laboratory tests
C0022885 (UMLS CUI-1)
Item
Has a blood sample been taken?
text
C0005834 (UMLS CUI [1])
Code List
Has a blood sample been taken?
CL Item
yes (please answer the following question if different from visit date) (1)
CL Item
no (2)
Date of blood sample
Item
Date of blood sample
date
C1317250 (UMLS CUI [1])
Item
Has a urine sample been taken?
text
C0430056 (UMLS CUI [1])
Code List
Has a urine sample been taken?
CL Item
yes (please answer the following question of different from visit date) (1)
CL Item
no (2)
CL Item
NA (not of childbearing potential or male) (3)
Date of pregnancy test
Item
Date of pregnancy test
date
C0032976 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Result from pregnancy test
text
C0427777 (UMLS CUI [1])
Code List
Result from pregnancy test
CL Item
negative (1)
CL Item
positive (2)
Item Group
Vaccine administration
C2368628 (UMLS CUI-1)
Date of vaccine administration
Item
Date of vaccine administration
date
C0011008 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
Pre-vaccination temperature
Item
Pre-vaccination temperature
float
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
Item
Route
text
Code List
Route
CL Item
Axillary (1)
CL Item
Oral (2)
CL Item
Rectal (3)
Item
Vaccacine administration
text
Code List
Vaccacine administration
CL Item
Twinrix™ Adult (720/20) Vaccine (1)
CL Item
Twinrix™ Adult (720/20) Vaccine: Not administered -> Please complete following page (2)
CL Item
Engerix™ (20 μg) Vaccine (3)
CL Item
Engerix™ (20 μg) Vaccine: Not administered -> Please complete following page (4)
CL Item
Havrix™ (720 EL.U)Vaccine (5)
CL Item
Havrix™ (720 EL.U)Vaccine: Not administered -> Please complete following page (6)
Item
Twinrix™ Adult (720/20) Vaccine: Has the study vaccine been administered according to the Protocol?
text
C0595042 (UMLS CUI [1,1])
C0547696 (UMLS CUI [1,2])
Code List
Twinrix™ Adult (720/20) Vaccine: Has the study vaccine been administered according to the Protocol?
CL Item
Yes (1)
CL Item
No (Please tick all Items that apply) (2)
Item
Twinrix™ Adult (720/20) Vaccine: specification of not administered according to the protocol
text
C0595042 (UMLS CUI [1,1])
C0547696 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Code List
Twinrix™ Adult (720/20) Vaccine: specification of not administered according to the protocol
CL Item
Side: left (1)
CL Item
Side: right (2)
CL Item
Site: Deltoid (3)
CL Item
Site: Thigh (4)
CL Item
Site: Buttock  (5)
CL Item
Route: I.M. (6)
CL Item
Route: S.C. (7)
Item
Engerix™ (20 μg) Vaccine: specification of not administered according to the protocol
text
C0116078 (UMLS CUI [1,1])
C0547696 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Code List
Engerix™ (20 μg) Vaccine: specification of not administered according to the protocol
CL Item
Side: Left (1)
CL Item
Side: Right (2)
CL Item
Site: Deltoid (3)
CL Item
Site: Thigh (4)
CL Item
Site: Buttock (5)
CL Item
Route: I.M. (6)
CL Item
Route: S.C. (7)
Item
Havrix™ (720 EL.U)Vaccine: specification of not administered according to the protocol
text
C0700881 (UMLS CUI [1,1])
C0547696 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Code List
Havrix™ (720 EL.U)Vaccine: specification of not administered according to the protocol
CL Item
Side: Left (1)
CL Item
Side: Right (2)
CL Item
Site: Deltoid (3)
CL Item
Site: Thigh (4)
CL Item
Site: Buttock (5)
CL Item
Route: I.M. (6)
CL Item
Route: S.C. (7)
Item
Why not administered?
text
C2368628 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Code List
Why not administered?
CL Item
Serious adverse event (complete Serious Adverse Event form) (1)
CL Item
Non-serious adverse event (complete the Non-serious Adverse Event section) (2)
CL Item
Other (3)
Specification of reason for non administration
Item
Other, please specify (reason for non administration)
text
C2368628 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Item
Please tick who took the decision
text
C0679006 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
Code List
Please tick who took the decision
CL Item
Investigator (1)
CL Item
Subject (2)
Item Group
Unsolicited adverse events
C0877248 (UMLS CUI-1)
C0042196 (UMLS CUI-2)
Item
Has the subject experienced any serious or non-serious unsolicited adverse events within one month post-vaccination?
text
C0877248 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
Code List
Has the subject experienced any serious or non-serious unsolicited adverse events within one month post-vaccination?
CL Item
Information not available (1)
CL Item
No Vaccine administered (2)
CL Item
No (3)
CL Item
Yes, fill in the Non-Serious Adverse Event pages or Serious Adverse Event form. (4)
Item Group
Soliticited adverse events - local symptoms
C0877248 (UMLS CUI-1)
C1457887 (UMLS CUI-2)
C0205276 (UMLS CUI-3)
Item
Has the subject experienced any of the following sings/symptoms at the administration site during the solicited period?
text
C0877248 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
Code List
Has the subject experienced any of the following sings/symptoms at the administration site during the solicited period?
CL Item
Information available (1)
CL Item
No Vaccine administered  (2)
CL Item
No (3)
CL Item
Yes, please tick No/Yes for each symptom. If Yes is ticked, please complete all items. (4)
Item
Local symptoms: Redness
text
C0041834 (UMLS CUI [1])
Code List
Local symptoms: Redness
CL Item
No (1)
CL Item
Size (please fill in next item) (2)
Erythema: day 0
Item
Local symptoms day 0
float
C0041834 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Erythema: day 1
Item
Local symptoms day 1
float
C0041834 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Erythema: day 2
Item
Local symptoms day 2
float
C0041834 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Erythema: day 3
Item
Local symptoms day 3
float
C0041834 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Erythema: Ongoing
Item
Ongoing after Day 3
boolean
C0041834 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Erythema: Date of last day of symptoms
Item
Date of last day of symptoms (redness)
date
C0041834 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1457887 (UMLS CUI [1,4])
Item
Local symptoms: swelling
text
C0038999 (UMLS CUI [1])
Code List
Local symptoms: swelling
CL Item
No (1)
CL Item
Yes (please fill in the next item) (2)
Swelling: day 0
Item
Local symptoms day 0
float
C0038999 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Swelling: day 1
Item
Local symptoms day 1
float
C0038999 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Swelling: day 2
Item
Local symptoms day 2
float
C0038999 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Swelling: day 3
Item
Local symptoms day 3
float
C0038999 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Swelling: Ongoing after Day 3
Item
Ongoing after Day 3
boolean
C0038999 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Swelling: Date of last day of symptoms
Item
Date of last day of symptoms (swelling)
date
C0038999 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1457887 (UMLS CUI [1,4])
Item
Local symptoms: pain
text
C1320357 (UMLS CUI [1])
Code List
Local symptoms: pain
CL Item
No (1)
CL Item
Yes, intensity: (please fill in next item) (2)
Item
Intensity of pain day 0
text
C1320357 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Code List
Intensity of pain day 0
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity of pain day 1
text
C1320357 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Code List
Intensity of pain day 1
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity of pain day 2
text
C1320357 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Code List
Intensity of pain day 2
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity of pain day 3
text
C1320357 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Code List
Intensity of pain day 3
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Intensity of pain: Ongoing after Day 3
Item
Ongoing after Day 3
boolean
C1320357 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Intensity of pain: Date of last day of symptoms
Item
Date of last day of symptoms (pain)
date
C1320357 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1457887 (UMLS CUI [1,4])
Item Group
Solicid adverse events - general symptoms
C0877248 (UMLS CUI-1)
C0159028 (UMLS CUI-2)
Item
Has the subject experienced any of the following signs/symptoms during the solicited period?
text
C0877248 (UMLS CUI [1,1])
C0159028 (UMLS CUI [1,2])
Code List
Has the subject experienced any of the following signs/symptoms during the solicited period?
CL Item
Information not available (1)
CL Item
No Vaccine administered (2)
CL Item
No (3)
CL Item
Yes, please tick No/Yes for each symptom. If Yes is ticked, please complete all items. (4)
Fever
Item
General symptoms: Fever
boolean
C0015967 (UMLS CUI [1])
Body Temperature
Item
Fever: if yes, please specify amount of fever
float
C0005903 (UMLS CUI [1])
Item
Taking temperature
text
C0886414 (UMLS CUI [1])
Code List
Taking temperature
CL Item
Axilary (1)
CL Item
Oral (2)
CL Item
Rectal (3)
Fever: day 0
Item
Fever day 0
float
C0015967 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Fever: Day 0 Specification
Item
Fever not taken day 0
boolean
C0015967 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Fever: day 1
Item
Fever day 1
float
C0015967 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Fever: Day 1 Specification
Item
Fever not taken day 1
boolean
C0015967 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Fever: day 2
Item
Fever day 2
float
C0015967 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Fever: Day 2 Specification
Item
Fever not taken day 2
boolean
C0015967 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Fever: day 3
Item
Fever day 3
float
C0015967 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Fever: Day 3 Specification
Item
Fever not taken day 3
boolean
C0015967 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Fever: Ongoing after Day 3
Item
Ongoing after Day 3
boolean
C0015967 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Fever: Date of last Day of Symptoms
Item
Date of last Day of Symptoms
date
C0015967 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1457887 (UMLS CUI [1,4])
Fever: Causality
Item
Causality
boolean
C0015967 (UMLS CUI [1,1])
C0015127 (UMLS CUI [1,2])
Item
Fatigue
text
C0015672 (UMLS CUI [1])
Code List
Fatigue
CL Item
No (1)
CL Item
Yes, please fill in next question (2)
Item
Intensity fatigue day 0
text
C0015672 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Code List
Intensity fatigue day 0
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity fatigue day 1
text
C0015672 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Code List
Intensity fatigue day 1
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity fatigue day 2
text
C0015672 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Code List
Intensity fatigue day 2
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity fatigue day 3
text
C0015672 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Code List
Intensity fatigue day 3
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Fatigue: Ongoing after Day 3
Item
Ongoing after Day 3
boolean
C0015672 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Fatigue: Date of last Day of symptoms
Item
Date of last Day of symptoms
date
C0015672 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1457887 (UMLS CUI [1,4])
Fatigue: Causality?
Item
Causality?
boolean
C0015672 (UMLS CUI [1,1])
C0015127 (UMLS CUI [1,2])
Item
Headache
text
C0018681 (UMLS CUI [1])
Code List
Headache
CL Item
No (1)
CL Item
Yes, intensity: please fill in the next items (2)
Item
Intensity headache day 0
text
C0018681 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Code List
Intensity headache day 0
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity headache day 1
text
C0018681 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Code List
Intensity headache day 1
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity headache day 2
text
C0018681 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Code List
Intensity headache day 2
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity headache day 3
text
C0018681 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Code List
Intensity headache day 3
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Headache: Ongoing after Day 3
Item
Ongoing after Day 3
boolean
C0018681 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Headache: Date of last Day of Symptoms
Item
Date of last Day of Symptoms
date
C0018681 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1457887 (UMLS CUI [1,4])
Headache: Causality
Item
Causality
boolean
C0018681 (UMLS CUI [1,1])
C0015127 (UMLS CUI [1,2])
Item
Gastrointestinal symptoms
text
C0426576 (UMLS CUI [1])
Code List
Gastrointestinal symptoms
CL Item
No (1)
CL Item
Yes, intensity: please fill in the next items (2)
Item
Intensity gastrointestinal symptoms day 0
text
C0426576 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Code List
Intensity gastrointestinal symptoms day 0
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity gastrointestinal symptoms day 1
text
C0426576 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Code List
Intensity gastrointestinal symptoms day 1
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity gastrointestinal symptoms day 2
text
C0426576 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Code List
Intensity gastrointestinal symptoms day 2
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Item
Intensity gastrointestinal symptoms day 3
text
C0426576 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Code List
Intensity gastrointestinal symptoms day 3
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
Gastrointestinal Symptoms: Ongoing after Day 3
Item
Ongoing after Day 3
boolean
C0426576 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Gastrointestinal Symptoms: Date of last day of symptoms
Item
Date of last day of symptoms
date
C0426576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1457887 (UMLS CUI [1,4])
Gastrointestinal Symptoms: Causality
Item
Causality
boolean
C0426576 (UMLS CUI [1,1])
C0015127 (UMLS CUI [1,2])

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