Subject number
Item
Subject number of previous study
integer
C2348585 (UMLS CUI [1])
Subject initials
Item
Subject initials first name family name
text
C1997894 (UMLS CUI [1,1])
C2986440 (UMLS CUI [1,2])
Date of birth
Item
Date of birth (day month year)
date
C0421451 (UMLS CUI [1])
Item
Please contact the following subjects for inclusion in the long-term follow-up study and document whether or not he/she agrees to participate.
integer
C0016441 (UMLS CUI [1,1])
C2348568 (UMLS CUI [1,2])
Code List
Please contact the following subjects for inclusion in the long-term follow-up study and document whether or not he/she agrees to participate.
CL Item
Subject not eligible (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: (3)
CL Item
please specify: ____________________ (4)
CL Item
other: please specify: ____________________ (5)
CL Item
Subject eligible and agreed to participate in the long-term follow-up study (4)
Date of Contact
Item
Date of Contact
date
C0011008 (UMLS CUI [1,1])
C1705415 (UMLS CUI [1,2])
Signature
Item
Investigator signature:
text
C2346576 (UMLS CUI [1])
Name of Investigator
Item
Investigator name
text
C2826892 (UMLS CUI [1])
Date
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])