Engelsk

End of study contact GSK study Chronic Coronary Heart Disease NCT00799903

1 Formulär  
End of study contact form
Beskrivning

End of study contact form

1. Was subject contacted?
Beskrivning

Please select No if continued attempts to contact subject have failed and 3 month EOS period had come to an end. If contact only made with Third party designee instead of subject please complete a THIRD PARTY form.

Datatyp

boolean

Type of contact
Beskrivning

Type of contact

Datatyp

integer

If telephone: Time of contact
Beskrivning

Time of contact

Datatyp

time

If telephone: Site staff who conducted call
Beskrivning

ensure documented in source notes

Datatyp

text

If telephone: Reason why visit was not perfomed in the clinic
Beskrivning

Reason visit was not perfomed in clinic

Datatyp

text

Other, specify
Beskrivning

Reason visit was not perfomed in clinic specification

Datatyp

text

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Similar models

End of study contact GSK study Chronic Coronary Heart Disease NCT00799903

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
End of study contact form
subject contact
Item
1. Was subject contacted?
boolean
Item
Type of contact
integer
Type of contact
Code List
Type of contact
CL Item
Clinic visit (1)
CL Item
Telephone (2)
Time of contact
Item
If telephone: Time of contact
time
Item
If telephone: Site staff who conducted call
text
Site staff who conducted call
Code List
If telephone: Site staff who conducted call
CL Item
Physician (34)
CL Item
Nurse (35)
CL Item
Other (OT)
Item
If telephone: Reason why visit was not perfomed in the clinic
text
Reason visit was not perfomed in clinic
Code List
If telephone: Reason why visit was not perfomed in the clinic
CL Item
Subject refused (1)
CL Item
Subject not able to visit clinic (2)
CL Item
Other (OT)
Reason visit was not perfomed in clinic specification
Item
Other, specify
text
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