ID

26475

Descrição

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.

Palavras-chave

Versões (2)
  1. 03/10/2017 03/10/2017 -
  2. 18/10/2017 18/10/2017 -
Titular dos direitos

GlaxoSmithKline

Transferido a

18 de outubro de 2017

DOI

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Licença

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

Inglês

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

1 Formulários  
PATIENT CONTINUATION/WITHDRAWAL
Descrição

PATIENT CONTINUATION/WITHDRAWAL

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

Is the patient continuing in the study?

Tipo de dados

integer

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

Is the patient continuing in the study?

Tipo de dados

integer

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

Is the patient continuing in the study?

Tipo de dados

text

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

INVESTIGATOR SIGNATURE

Alias
UMLS CUI-1
C2346576
Investigator’s Signature
Descrição

Investigator’s Signature

Tipo de dados

text

Alias
UMLS CUI [1]
C2346576
Date
Descrição

Date

Tipo de dados

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Voltar ao início da página

Similar models

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

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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])
Voltar ao início da página 

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