ID

26475

Description

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.

Mots-clés

Versions (2)
  1. 03/10/2017 03/10/2017 -
  2. 18/10/2017 18/10/2017 -
Détendeur de droits

GlaxoSmithKline

Téléchargé le

18 octobre 2017

DOI

Pour une demande vous connecter.

Licence

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

Anglais

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

1 Formulaires  
PATIENT CONTINUATION/WITHDRAWAL
Description

PATIENT CONTINUATION/WITHDRAWAL

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

Is the patient continuing in the study?

Type de données

integer

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

Is the patient continuing in the study?

Type de données

integer

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

Is the patient continuing in the study?

Type de données

text

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

INVESTIGATOR SIGNATURE

Alias
UMLS CUI-1
C2346576
Investigator’s Signature
Description

Investigator’s Signature

Type de données

text

Alias
UMLS CUI [1]
C2346576
Date
Description

Date

Type de données

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 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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])
Retour au début de la page 

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