Inglés

study conclusion Ropinirole CR Ropinirole IR Monotherapy 101468/168

1 formularios  
Administrative Data
Descripción

Administrative Data

Alias
UMLS CUI-1
C1320722
Subject Number
Descripción

subject number

Tipo de datos

integer

Alias
UMLS CUI [1]
C2348585
STUDY CONCLUSION
Descripción

STUDY CONCLUSION

Date of subject completion or withdrawal
Descripción

Date of subject completion or withdrawal

Tipo de datos

date

Did the subject withdraw from study as a result of this AE?
Descripción

Withdrawal

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1710677
UMLS CUI [1,2]
C1518404
Primary reason for withdrawal
Descripción

Primary reason for withdrawal

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0392360
Other, specify
Descripción

Other primary reason for withdrawal

Tipo de datos

text

PREGNANCY INFORMATION
Descripción

PREGNANCY INFORMATION

Did the subject become pregnant during the study?
Descripción

If Yes, complete Pregnancy Notification form.

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0032961
UMLS CUI [1,2]
C0008976
OVERALL COMPLIANCE
Descripción

OVERALL COMPLIANCE

Did the subject generally take their morning dose of medication within 2 hours of a meal?
Descripción

Overall compliance

Tipo de datos

boolean

INVESTIGATOR’S SIGNATURE
Descripción

INVESTIGATOR’S SIGNATURE

Investigator’s Signature
Descripción

I confirm that I have reviewed the data in this Case Report Form for this subject. All information entered by myself or my colleagues is, to the best of my knowledge, complete and accurate, as of the date below

Tipo de datos

text

Alias
UMLS CUI [1]
C2346576
Investigator’s name (print)
Descripción

InvestigatorName

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035173
UMLS CUI [1,2]
C0600091
UMLS CUI [1,3]
C1547383
Date
Descripción

Investigator Signature Date

Tipo de datos

date

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

study conclusion Ropinirole CR Ropinirole IR Monotherapy 101468/168

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
subject number
Item
Subject Number
integer
C2348585 (UMLS CUI [1])
Item Group
STUDY CONCLUSION
Date of subject completion or withdrawal
Item
Date of subject completion or withdrawal
date
Item
Did the subject withdraw from study as a result of this AE?
text
C1710677 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Withdrawal
Code List
Did the subject withdraw from study as a result of this AE?
CL Item
No (N)
CL Item
Yes (Y)
Item
Primary reason for withdrawal
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Primary reason for withdrawal
Code List
Primary reason for withdrawal
CL Item
Adverse event (record details on the Non-Serious Adverse Event or Serious Adverse Events forms as appropriate) (1)
CL Item
Lost to follow-up (2)
CL Item
Protocol violation (3)
CL Item
Subject decided to withdraw from the study (4)
CL Item
Lack of efficacy (5)
CL Item
Sponsor terminated study (6)
CL Item
Non-compliance (17)
CL Item
Other (Z)
Other primary reason for withdrawal
Item
Other, specify
text
Item Group
PREGNANCY INFORMATION
Item
Did the subject become pregnant during the study?
text
C0032961 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
pregnancy during study
Code List
Did the subject become pregnant during the study?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not applicable (Not of childbearing potential or male) (Not applicable)
Item Group
OVERALL COMPLIANCE
Overall compliance
Item
Did the subject generally take their morning dose of medication within 2 hours of a meal?
boolean
Item Group
INVESTIGATOR’S SIGNATURE
Investigator Signature
Item
Investigator’s Signature
text
C2346576 (UMLS CUI [1])
InvestigatorName
Item
Investigator’s name (print)
text
C0035173 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C1547383 (UMLS CUI [1,3])
Investigator Signature Date
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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