Monitor Data Validation Check
Item
Pregnancy Information: Check that responses provided correspond with the sex of the subject.
text
C1519941 (UMLS CUI [1,1])
C1516647 (UMLS CUI [1,2])
C0032961 (UMLS CUI [1,3])
Subject Identifier
Item
Subject Identifier
integer
C2348585 (UMLS CUI [1])
Item
Did the subject become pregnant during the study?
text
C0032961 (UMLS CUI [1])
Code List
Did the subject become pregnant during the study?
CL Item
Yes (Complete the Pregnancy Notification form) (Y)
CL Item
Not Applicable (not of childbearing potential or male) (X)
Item
Was the treatment blind broken during the study?
text
C2347038 (UMLS CUI [1,1])
C3897431 (UMLS CUI [1,2])
Code List
Was the treatment blind broken during the study?
Date blind broken
Item
Date blind broken
date
C0011008 (UMLS CUI [1,1])
C3899531 (UMLS CUI [1,2])
Item
Reason blind broken
text
C0392360 (UMLS CUI [1])
Code List
Reason blind broken
CL Item
Medical emergency requiring identification of investigational product for further treatment (1)
CL Item
Other,specify (2)
Reason blind broken
Item
Specify other reason for unblinding
text
C3897431 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
C3845569 (UMLS CUI [1,3])
Investigator Instructions
Item
A medically qualified Sub-investigator may sign this page; however, the Investigator remains accountable for CRF data.
text
C0008961 (UMLS CUI [1,1])
C1442085 (UMLS CUI [1,2])
Study Conclusion Investigator Instructions
Item
Refer to protocol section(s) (insert protocol section number(s)) to evaluate subject completion or withdrawal from the study. • If subject completed study: Date of subject completion or withdrawal must match the last scheduled study visit date. • If subject withdrew and a withdrawal visit was conducted: Date of subject completion or withdrawal must match the date of subject withdrawal. • If subject lost to follow-up: Date of subject completion or withdrawal must match the last actual contact with the subject whether or not the contact was a clinic visit. Do not record dates of unsuccessful attempts to contact the subject. • Adverse event: includes adverse events, serious adverse events, death (see protocol section 10). • Protocol violation: includes use of prohibited/conditional medications (see protocol section 8.2). • Subject decided to withdraw from the study: includes caregiver decision to withdraw the subject. • Non-compliance: includes non-compliance with study medication (see protocol section 7.11 ), or with study visits/ procedures.
text
C1707478 (UMLS CUI [1,1])
C0008972 (UMLS CUI [1,2])
C1442085 (UMLS CUI [1,3])
Date of subject completion or withdrawal
Item
Date of subject completion or withdrawal
date
C0011008 (UMLS CUI [1,1])
C0805732 (UMLS CUI [1,2])
C2349954 (UMLS CUI [1,3])
Item
Was the subject withdrawn from the study?
text
C0422727 (UMLS CUI [1])
Code List
Was the subject withdrawn from the study?
Item
What was the primary reason for withdrawal?
text
C2349954 (UMLS CUI [1,1])
C1549995 (UMLS CUI [1,2])
Code List
What was the primary reason for withdrawal?
CL Item
Adverse event (record details on the Non-Serious Adverse Event or Serious Adverse Event pages as appropriate) (1)
CL Item
Lost to follow-up (2)
CL Item
Protocol violation (3)
CL Item
Subject decided to withdraw from the study (4)
CL Item
Sponsor terminated study (6)
CL Item
Non-compliance (17)
CL Item
Other, specify (Z)
withdrawal reason
Item
If OTHER, please specify
text
C2349954 (UMLS CUI [1,1])
C1549995 (UMLS CUI [1,2])
Investigator Signature
Item
Investigator Signature
text
C2346576 (UMLS CUI [1])
Investigator name
Item
Printed Investigators name
text
C2826892 (UMLS CUI [1])
Date of completion
Item
Date
date
C0011008 (UMLS CUI [1,1])
C0850287 (UMLS CUI [1,2])
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