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Patient Death Ropinirole in Parkinson's Disease GSK 101468/196

1 forms  
Patient Information
Description

Patient Information

Alias
UMLS CUI-1
C1955348
Patient No.
Description

Patient Number

Data type

text

Alias
UMLS CUI [1]
C1830427
Patient Death - In case of patient death, please complete the following information:
Description

Patient Death - In case of patient death, please complete the following information:

Alias
UMLS CUI-1
C0011065
Date of Death:
Description

Date of Death

Data type

date

Measurement units
  • dd-mmm-yyyy
Alias
UMLS CUI [1]
C1148348
dd-mmm-yyyy
Was an autopsy performed?
Description

If YES, attach a copy of the autopsy report.

Data type

boolean

Alias
UMLS CUI [1]
C0004398
Primary Cause of Death:
Description

Primary Cause of Death

Data type

text

Alias
UMLS CUI [1]
C3262229
Underlying cause(s) of Death:
Description

Cause of Death

Data type

text

Alias
UMLS CUI [1]
C0007465
Was death related to study drug?
Description

Death related to Study Drug

Data type

boolean

Alias
UMLS CUI [1,1]
C0011065
UMLS CUI [1,2]
C0304229
Signature of Investigator:
Description

Investigator's Signature

Data type

text

Alias
UMLS CUI [1]
C2346576
Date
Description

Date of Report

Data type

date

Measurement units
  • dd-mmm-yyyy
Alias
UMLS CUI [1]
C1302584
dd-mmm-yyyy
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Similar models

Patient Death Ropinirole in Parkinson's Disease GSK 101468/196

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient Information
C1955348 (UMLS CUI-1)
Patient Number
Item
Patient No.
text
C1830427 (UMLS CUI [1])
Item Group
Patient Death - In case of patient death, please complete the following information:
C0011065 (UMLS CUI-1)
Date of Death
Item
Date of Death:
date
C1148348 (UMLS CUI [1])
Autopsy
Item
Was an autopsy performed?
boolean
C0004398 (UMLS CUI [1])
Primary Cause of Death
Item
Primary Cause of Death:
text
C3262229 (UMLS CUI [1])
Cause of Death
Item
Underlying cause(s) of Death:
text
C0007465 (UMLS CUI [1])
Death related to Study Drug
Item
Was death related to study drug?
boolean
C0011065 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
Investigator's Signature
Item
Signature of Investigator:
text
C2346576 (UMLS CUI [1])
Date of Report
Item
Date
date
C1302584 (UMLS CUI [1])
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