Inglés

Serious Adverse Event

1 formularios  
  1. StudyEvent: ODM
    1. Serious Adverse Event
Administrative Documentation
Descripción

Administrative Documentation

Alias
UMLS CUI-1
C1320722
Subject Number
Descripción

Subject Number

Tipo de datos

text

Alias
UMLS CUI [1]
C2348585
Visit Date
Descripción

Visit Date

Tipo de datos

date

Alias
UMLS CUI [1]
C1320303
Serious Adverse Event (SAE)
Descripción

Serious Adverse Event (SAE)

Alias
UMLS CUI-1
C1519255
Person Reporting SAE (Please print clearly)
Descripción

Reporting Person

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C0700287
AEGIS Number
Descripción

Reporter Identifier

Tipo de datos

float

Alias
UMLS CUI [1,1]
C0237753
UMLS CUI [1,2]
C0600091
Serious Adverse Event (Please print clearly)
Descripción

Serious Adverse Event

Tipo de datos

text

Alias
UMLS CUI [1]
C1519255
Specify reason(s) for considering this a serious AE. Mark all that apply.
Descripción

Reason Adverse Event

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C1519255
GSK Use
Descripción

GSK Use

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0008961
UMLS CUI [1,2]
C0457083
Onset Date and Time
Descripción

Date | Time

Tipo de datos

datetime

Alias
UMLS CUI [1,1]
C2826806
UMLS CUI [1,2]
C1519255
End Date and Time (if ongoing please leave blank)
Descripción

End Date Time

Tipo de datos

datetime

Alias
UMLS CUI [1]
C2826793
Outcome *If subject died, please inform GSK within 24 hours and complete Form D
Descripción

Adverse Event Outcome

Tipo de datos

text

Alias
UMLS CUI [1]
C1705586
Event Course
Descripción

Course

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0750729
UMLS CUI [1,2]
C1519255
Intensity (Maximum)
Descripción

Intensity

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1710066
UMLS CUI [1,2]
C1519255
Action Taken with Respect to Investigational Drug
Descripción

Action Taken

Tipo de datos

text

Alias
UMLS CUI [1]
C2826626
Did the SAE abate?
Descripción

Abation

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C3853704
assessment of adverse event
Descripción

Adverse event association C0877248

Tipo de datos

text

If yes, did SAE recur?
Descripción

Recurring Adverse Event

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1709874
UMLS CUI [1,2]
C1519255
Relationship to lnvestigational Drug
Descripción

Drug relationship

Tipo de datos

text

Alias
UMLS CUI [1]
C0277579
The SAE is probably associated with:
Descripción

Adverse event assessment

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C3846158
Corrective Therapy If 'Yes' Please record on Concomitant Medication form
Descripción

Corrective therapy

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Was subject withdrawn due to this AE ?
Descripción

Withdrawal

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C1519255
Remarks (Please provide a brief narrative description of the SAE, attaching extra pages eg. hospital discharge summary if necessary)
Descripción

SAE Remarks

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0947611
Relevant Laboratory Data Please provide relevant abnormal laboratory data below
Descripción

Relevant Laboratory Data Please provide relevant abnormal laboratory data below

Alias
UMLS CUI-1
C1705214
Test
Descripción

Test

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0332307
Date
Descripción

Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0011008
Value
Descripción

Value

Tipo de datos

text

Alias
UMLS CUI [1]
C0587081
Units
Descripción

Unit

Tipo de datos

text

Alias
UMLS CUI [1]
C1519795
Normal Range
Descripción

Normal Range

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0086715
Administrative Documentation
Descripción

Administrative Documentation

Alias
UMLS CUI-1
C1320722
If applicable, was randomisation code broken at investigational site?
Descripción

Randomisation Code

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0034656
UMLS CUI [1,2]
C3899531
Randomisation/Study Medication Number:
Descripción

Randomisation Number | Study Medication Number

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0034656
UMLS CUI [1,2]
C0237753
Investigator's Signature: (confirming that the above data are accurate and complete)
Descripción

Investigator Signature

Tipo de datos

text

Alias
UMLS CUI [1]
C2346576
Date
Descripción

Investigator Signature Date

Tipo de datos

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Please PRINT Name
Descripción

Printed Name

Tipo de datos

text

Alias
UMLS CUI [1]
C2826892
GSK Medical Monitor's Signature:
Descripción

Investigator Use

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0008961
UMLS CUI [1,2]
C0457083
UMLS CUI [1,3]
C1519316
Investigator Use
Descripción

Investigator Use

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0008961
UMLS CUI [1,2]
C0457083
UMLS CUI [1,3]
C2346576
UMLS CUI [1,4]
C0011008
Please PRINT Name
Descripción

Printed Name

Tipo de datos

text

Alias
UMLS CUI [1]
C2826892
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Similar models

Serious Adverse Event

1 formularios
  1. StudyEvent: ODM
    1. Serious Adverse Event
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative Documentation
C1320722 (UMLS CUI-1)
Subject Number
Item
Subject Number
text
C2348585 (UMLS CUI [1])
Visit Date
Item
Visit Date
date
C1320303 (UMLS CUI [1])
Item Group
Serious Adverse Event (SAE)
C1519255 (UMLS CUI-1)
Reporting Person
Item
Person Reporting SAE (Please print clearly)
text
C0027361 (UMLS CUI [1,1])
C0700287 (UMLS CUI [1,2])
Reporter Identifier
Item
AEGIS Number
float
C0237753 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Serious Adverse Event
Item
Serious Adverse Event (Please print clearly)
text
C1519255 (UMLS CUI [1])
Item
Specify reason(s) for considering this a serious AE. Mark all that apply.
text
C0566251 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Reason Adverse Event
Code List
Specify reason(s) for considering this a serious AE. Mark all that apply.
CL Item
Results in Death (A)
CL Item
Life threatening (B)
CL Item
Requires Hospitalisation or prolongation of existing hospitalization (C)
CL Item
Results in disability/incapacity (D)
CL Item
Congenital anomaly/birth defect (E)
CL Item
other (see definition) (F)
GSK Use
Item
GSK Use
text
C0008961 (UMLS CUI [1,1])
C0457083 (UMLS CUI [1,2])
Date | Time
Item
Onset Date and Time
datetime
C2826806 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
End Date Time
Item
End Date and Time (if ongoing please leave blank)
datetime
C2826793 (UMLS CUI [1])
Item
Outcome *If subject died, please inform GSK within 24 hours and complete Form D
text
C1705586 (UMLS CUI [1])
Adverse Event Outcome
Code List
Outcome *If subject died, please inform GSK within 24 hours and complete Form D
CL Item
Resolved (Resolved)
CL Item
Ongoing (Ongoing)
CL Item
Died* (Died*)
Item
Event Course
text
C0750729 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Course
Code List
Event Course
CL Item
Intermittent (Number of episodes) (1)
CL Item
Constant (2)
Item
Intensity (Maximum)
text
C1710066 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Intensity
Code List
Intensity (Maximum)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Item
Action Taken with Respect to Investigational Drug
text
C2826626 (UMLS CUI [1])
Action Taken
Code List
Action Taken with Respect to Investigational Drug
CL Item
None (None)
CL Item
Dose reduced (Dose reduced)
CL Item
Dose increased (Dose increased)
CL Item
Dose interrupted/restarted (Dose interrupted/restarted)
CL Item
Drug stopped (Drug stopped)
Abation
Item
Did the SAE abate?
boolean
C1519255 (UMLS CUI [1,1])
C3853704 (UMLS CUI [1,2])
assessment of adverse event
Item
text
Recurring Adverse Event
Item
If yes, did SAE recur?
boolean
C1709874 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item
Relationship to lnvestigational Drug
text
C0277579 (UMLS CUI [1])
Drug relationship
Code List
Relationship to lnvestigational Drug
CL Item
Not related (Not related)
CL Item
Unlikely (Unlikely)
CL Item
Suspected (reasonable possibility) (Suspected (reasonable possibility))
CL Item
Probable (Probable)
Item
The SAE is probably associated with:
text
C0877248 (UMLS CUI [1,1])
C3846158 (UMLS CUI [1,2])
Adverse event assessment
Code List
The SAE is probably associated with:
CL Item
Protocol design or procedures (but not to study drug) Please specify (Protocol design or procedures (but not to study drug) Please specify)
CL Item
Another condition (eg, condition under study, intercurrent illness) Please specify (Another condition (eg, condition under study, intercurrent illness) Please specify)
CL Item
Another drug Please specify (Another drug Please specify)
Corrective therapy
Item
Corrective Therapy If 'Yes' Please record on Concomitant Medication form
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Withdrawal
Item
Was subject withdrawn due to this AE ?
boolean
C2349954 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
SAE Remarks
Item
Remarks (Please provide a brief narrative description of the SAE, attaching extra pages eg. hospital discharge summary if necessary)
text
C1519255 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Item Group
Relevant Laboratory Data Please provide relevant abnormal laboratory data below
C1705214 (UMLS CUI-1)
Test
Item
Test
text
C0022885 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Value
Item
Value
text
C0587081 (UMLS CUI [1])
Unit
Item
Units
text
C1519795 (UMLS CUI [1])
Normal Range
Item
Normal Range
text
C0022885 (UMLS CUI [1,1])
C0086715 (UMLS CUI [1,2])
Item Group
C1320722 (UMLS CUI-1)
Randomisation Code
Item
If applicable, was randomisation code broken at investigational site?
boolean
C0034656 (UMLS CUI [1,1])
C3899531 (UMLS CUI [1,2])
Randomisation Number | Study Medication Number
Item
Randomisation/Study Medication Number:
integer
C0034656 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Investigator Signature
Item
Investigator's Signature: (confirming that the above data are accurate and complete)
text
C2346576 (UMLS CUI [1])
Investigator Signature Date
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Printed Name
Item
Please PRINT Name
text
C2826892 (UMLS CUI [1])
Investigator Use
Item
GSK Medical Monitor's Signature:
text
C0008961 (UMLS CUI [1,1])
C0457083 (UMLS CUI [1,2])
C1519316 (UMLS CUI [1,3])
Investigator Use
Item
date
C0008961 (UMLS CUI [1,1])
C0457083 (UMLS CUI [1,2])
C2346576 (UMLS CUI [1,3])
C0011008 (UMLS CUI [1,4])
Printed Name
Item
Please PRINT Name
text
C2826892 (UMLS CUI [1])
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