ID

26475

Beschrijving

Study ID: 101468/190 Clinical Study ID: SKF-101468/190 Study Title:A 12 Week, Double-Blind, Placebo-Controlled, Parallel Group Study to Assess the Efficacy and Safety of Ropinirole in Patients Suffering from Restless Legs Syndrome (RLS). Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Requip Study Indication: Restless Legs Syndrome This is the Patient Continuation Withdrawal form.

Trefwoorden

Versies (2)
  1. 03-10-17 03-10-17 -
  2. 18-10-17 18-10-17 -
Houder van rechten

GlaxoSmithKline

Geüploaded op

18 oktober 2017

DOI

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Licentie

Creative Commons BY-NC 3.0
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Patient Continuation Withdrawal GSK Ropinirole in Patients Suffering from Restless Legs Syndrome 101468/190

Engels

Patient Continuation Withdrawal GSK Ropinirole in Patients Suffering from Restless Legs Syndrome 101468/190

1 Formulieren  
PATIENT CONTINUATION/WITHDRAWAL
Beschrijving

PATIENT CONTINUATION/WITHDRAWAL

Alias
UMLS CUI-1
C2348568
Is the patient continuing in the study?
Beschrijving

Is the patient continuing in the study?

Datatype

integer

Alias
UMLS CUI [1]
C2348568
Is the patient continuing in the study?
Beschrijving

Is the patient continuing in the study?

Datatype

integer

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C0392360
Is the patient continuing in the study? Please specify:
Beschrijving

Is the patient continuing in the study?

Datatype

text

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C0392360
UMLS CUI [1,3]
C0205394
INVESTIGATOR SIGNATURE
Beschrijving

INVESTIGATOR SIGNATURE

Alias
UMLS CUI-1
C2346576
Investigator’s Signature
Beschrijving

Investigator’s Signature

Datatype

text

Alias
UMLS CUI [1]
C2346576
Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
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Similar models

Patient Continuation Withdrawal GSK Ropinirole in Patients Suffering from Restless Legs Syndrome 101468/190

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
PATIENT CONTINUATION/WITHDRAWAL
C2348568 (UMLS CUI-1)
Item
Is the patient continuing in the study?
integer
C2348568 (UMLS CUI [1])
Is the patient continuing in the study?
Code List
Is the patient continuing in the study?
CL Item
Yes (1)
CL Item
No If ’No’, please mark the primary cause of withdrawal. (Mark one box only). (2)
Item
Is the patient continuing in the study?
integer
C2348568 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Is the patient continuing in the study?
Code List
Is the patient continuing in the study?
CL Item
Baseline sign and symptom (please complete Baseline Signs and Symptoms page) (1)
CL Item
Does not meet inclusion/exclusion criteria (2)
CL Item
Protocol deviation (including non-compliance) (3)
CL Item
Lost to follow-up (4)
CL Item
Other - specify: (5)
Is the patient continuing in the study?
Item
Is the patient continuing in the study? Please specify:
text
C2348568 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item Group
INVESTIGATOR SIGNATURE
C2346576 (UMLS CUI-1)
Investigator’s Signature
Item
Investigator’s Signature
text
C2346576 (UMLS CUI [1])
Date
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Terug naar het begin van de pagina 

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