Patient Continuation
Item
Is the patient continuing in the study?
boolean
C2348568 (UMLS CUI [1])
Item
If ’No’, please mark the primary cause of withdrawal. (Mark one box only).
integer
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Code List
If ’No’, please mark the primary cause of withdrawal. (Mark one box only).
CL Item
Baseline sign and symptom (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)
primary cause of withdrawal
Item
Primary cause of withdrawal: If 'Other', please specify
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Investigator’s Signature
Item
Investigator’s Signature
text
C2346576 (UMLS CUI [1])
Investigator’s Signature Date
Item
Investigator’s Signature Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])