Center Number
Item
Center
integer
C1301943 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
Investigator Name
Item
Investigator name: (please PRINT name)
text
C2826892 (UMLS CUI [1])
Investigator signature
Item
Signature
text
C2346576 (UMLS CUI [1])
Signature date
Item
Date
date
C0011008 (UMLS CUI [1,1])
C2346576 (UMLS CUI [1,2])
Previous subject number
Item
Previous subject number
integer
C2348585 (UMLS CUI [1,1])
C0205156 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Please document reason for non participation
text
C0558080 (UMLS CUI [1,1])
C0679823 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Code List
Please document reason for non participation
CL Item
Subject not eligible? - please specify criteria that are not fullfilled: (1)
CL Item
Subject lost to follow-up or not reached (2)
CL Item
Subject eligible but not willing to participate due to:adverse events, or serious adverse event: please specify: (3)
CL Item
Subject eligible but not willing to participate due to other: please specify: (4)
CL Item
Subject died on (5)
Reason for non participation
Item
Please document reason for non participation, Specification
text
C0558080 (UMLS CUI [1,1])
C0679823 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
Date of contact
Item
Date of contact
date
C0011008 (UMLS CUI [1,1])
C1705415 (UMLS CUI [1,2])