ID
29748
Beschreibung
https://clinicaltrials.gov/show/NCT00197028 Sample Case Report Form Study ID: 103967 Clinical Study ID: 103967 Study Title: A Phase I/IIb randomized, double-blind, controlled study of the safety, immunogenicity and proof-of-concept of RTS,S/AS02D, a candidate malaria vaccine in infants living in a malaria-endemic region Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00197028 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 2 Study Recruitment Status: Completed Generic Name: SB257049 Trade Name: BIO MALARIA; SB257049 Study Indication: Malaria
Link
https://clinicaltrials.gov/show/NCT00197028
Stichworte
Versionen (1)
- 18.04.18 18.04.18 -
Rechteinhaber
GlaxoSmithKline (GSK)
Hochgeladen am
18. April 2018
DOI
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Lizenz
Creative Commons BY-NC 3.0
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RTS,S/AS02D, a candidate malaria vaccine in infants living in a malaria-endemic region, Study ID: 103967, NCT00197028
Sample Case Report Form: Laboratory Reference Ranges and Serious Adverse Events
Beschreibung
Reference Range
Alias
- UMLS CUI-1
- C0883335
Beschreibung
Date of reference range
Datentyp
date
Alias
- UMLS CUI [1,1]
- C0883335
- UMLS CUI [1,2]
- C0011008
Beschreibung
Age range
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0001779
- UMLS CUI [1,2]
- C1514721
Beschreibung
Age units
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1519795
- UMLS CUI [1,2]
- C0001779
Beschreibung
Sex
Datentyp
integer
Alias
- UMLS CUI [1]
- C0079399
Beschreibung
Laboratory Test
Datentyp
integer
Alias
- UMLS CUI [1]
- C0022885
Beschreibung
Laboratory test unit
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0022885
- UMLS CUI [1,2]
- C0439148
Beschreibung
Low Reference Value
Datentyp
float
Alias
- UMLS CUI [1,1]
- C0587081
- UMLS CUI [1,2]
- C1522609
- UMLS CUI [1,3]
- C0205251
Beschreibung
High Reference value
Datentyp
float
Alias
- UMLS CUI [1,1]
- C0587081
- UMLS CUI [1,2]
- C1522609
- UMLS CUI [1,3]
- C0205250
Beschreibung
Serious adverse events
Alias
- UMLS CUI-1
- C1519255
Beschreibung
Center number
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1301943
- UMLS CUI [1,2]
- C0600091
Beschreibung
Country
Datentyp
text
Alias
- UMLS CUI [1]
- C0454664
Beschreibung
GSK Receipt Date
Datentyp
date
Alias
- UMLS CUI [1]
- C2985846
Beschreibung
Subject Number
Datentyp
integer
Alias
- UMLS CUI [1]
- C2348585
Beschreibung
Type of information
Datentyp
integer
Alias
- UMLS CUI [1]
- C1508263
Beschreibung
Serious adverse event number
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C0237753
Beschreibung
Section 1
Alias
- UMLS CUI-1
- C1519255
- UMLS CUI-2
- C1828479
Beschreibung
Event
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C0011900
Beschreibung
Start date
Datentyp
date
Alias
- UMLS CUI [1]
- C2697888
Beschreibung
Outcome
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1705586
- UMLS CUI [1,2]
- C1519255
Beschreibung
If fatal, record date of death
Datentyp
date
Alias
- UMLS CUI [1]
- C2697886
Beschreibung
Maximum intensity
Datentyp
integer
Alias
- UMLS CUI [1]
- C1710066
Beschreibung
Action taken with investigational product(s)
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1704758
- UMLS CUI [1,2]
- C1519255
Beschreibung
(*) If yes, please complete the Study Conclusion page in the CRF of the subject and tick SAE as reason for withdrawal
Datentyp
boolean
Alias
- UMLS CUI [1,1]
- C2349954
- UMLS CUI [1,2]
- C1519255
Beschreibung
Relationship to investigational product(s)
Datentyp
boolean
Alias
- UMLS CUI [1,1]
- C0304229
- UMLS CUI [1,2]
- C0085978
- UMLS CUI [1,3]
- C1519255
Beschreibung
HO:Hospitalisation ER:Emergency Room MD:Medical Doctor Refer to protocol for full definition
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0545082
- UMLS CUI [1,2]
- C1386497
- UMLS CUI [1,3]
- C1519255
Beschreibung
If yes, summarize findings in narrative remarks section of this SAE form.
Datentyp
boolean
Alias
- UMLS CUI [1,1]
- C0004398
- UMLS CUI [1,2]
- C1519255
Beschreibung
Section 2
Alias
- UMLS CUI-1
- C1828479
- UMLS CUI-2
- C1710056
Beschreibung
Seriousness
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1710056
- UMLS CUI [1,2]
- C1519255
Beschreibung
Section 3 - Demography Data
Alias
- UMLS CUI-1
- C1828479
- UMLS CUI-2
- C0011298
Beschreibung
Date of birth
Datentyp
date
Alias
- UMLS CUI [1]
- C0421451
Beschreibung
Sex
Datentyp
integer
Alias
- UMLS CUI [1]
- C0079399
Beschreibung
Weight
Datentyp
float
Maßeinheiten
- kg
Alias
- UMLS CUI [1]
- C0005910
Beschreibung
Weight
Datentyp
integer
Maßeinheiten
- pounds/ounces
Alias
- UMLS CUI [1]
- C0005910
Beschreibung
Section 4
Alias
- UMLS CUI-1
- C1828479
Beschreibung
Section 5 - Causes of SAE
Alias
- UMLS CUI-1
- C1519255
- UMLS CUI-2
- C0085978
Beschreibung
Causes of SAE
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C0085978
Beschreibung
Section 6 – Relevant Medical Conditions
Alias
- UMLS CUI-1
- C0012634
- UMLS CUI-2
- C0262926
- UMLS CUI-3
- C1519255
Beschreibung
Medical disorders
Datentyp
text
Alias
- UMLS CUI [1]
- C0012634
- UMLS CUI [2]
- C0020517
- UMLS CUI [3]
- C0543467
Beschreibung
Date of onset
Datentyp
date
Alias
- UMLS CUI [1,1]
- C0574845
- UMLS CUI [1,2]
- C0012634
Beschreibung
Present condition
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0012634
- UMLS CUI [2]
- C1519255
Beschreibung
Date of last occurence
Datentyp
date
Alias
- UMLS CUI [1,1]
- C0012634
- UMLS CUI [1,2]
- C0011008
- UMLS CUI [1,3]
- C2745955
Beschreibung
Section 7 - Other relevant risk factors
Alias
- UMLS CUI-1
- C1828479
- UMLS CUI-2
- C0035648
Beschreibung
Section 8 – Relevant Concomitant Medications
Alias
- UMLS CUI-1
- C1828479
- UMLS CUI-2
- C2347852
Beschreibung
Drug name
Datentyp
text
Alias
- UMLS CUI [1,1]
- C2360065
- UMLS CUI [1,2]
- C2347852
Beschreibung
Dose
Datentyp
integer
Alias
- UMLS CUI [1]
- C3174092
Beschreibung
Unit
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1519795
- UMLS CUI [1,2]
- C2347852
Beschreibung
Frequency
Datentyp
text
Alias
- UMLS CUI [1,1]
- C3476109
- UMLS CUI [1,2]
- C2347852
Beschreibung
Route
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0013153
- UMLS CUI [1,2]
- C2347852
Beschreibung
Concomitant Medications
Datentyp
boolean
Alias
- UMLS CUI [1]
- C2347852
Beschreibung
Date started
Datentyp
date
Alias
- UMLS CUI [1]
- C2826734
Beschreibung
Date stopped
Datentyp
date
Alias
- UMLS CUI [1]
- C2826744
Beschreibung
Ongoing
Datentyp
boolean
Alias
- UMLS CUI [1]
- C2826666
Beschreibung
Reason for medication
Datentyp
text
Alias
- UMLS CUI [1]
- C2826696
Beschreibung
Section 9 – Details of investigational product(s)
Alias
- UMLS CUI-1
- C1828479
- UMLS CUI-2
- C0013230
- UMLS CUI-3
- C1522508
Beschreibung
Vaccine
Datentyp
text
Alias
- UMLS CUI [1]
- C0042210
Beschreibung
Dose number
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1115464
- UMLS CUI [1,2]
- C0042210
Beschreibung
Lot number
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C2826710
- UMLS CUI [1,2]
- C0042210
Beschreibung
Route / site
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0013153
- UMLS CUI [1,2]
- C0042210
- UMLS CUI [2]
- C1515974
Beschreibung
Administration date
Datentyp
date
Alias
- UMLS CUI [1,1]
- C1533734
- UMLS CUI [1,2]
- C0011008
- UMLS CUI [1,3]
- C0042210
Beschreibung
Randomization code
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0034656
- UMLS CUI [1,2]
- C0443289
Beschreibung
Section 10 – Details of relevant assessments
Alias
- UMLS CUI-1
- C1828479
- UMLS CUI-2
- C0220825
Beschreibung
Details of relevant assessments
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C1261322
- UMLS CUI [1,3]
- C1522508
Beschreibung
Section 11 – Narrative remarks
Alias
- UMLS CUI-1
- C1828479
- UMLS CUI-2
- C0947611
Beschreibung
Section 12 – SAE additional / follow-up information
Alias
- UMLS CUI-1
- C1524062
- UMLS CUI-2
- C1533716
- UMLS CUI-3
- C1519255
- UMLS CUI-4
- C1522577
Beschreibung
SAE additional / follow-up information
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1524062
- UMLS CUI [1,2]
- C1533716
- UMLS CUI [1,3]
- C1519255
- UMLS CUI [1,4]
- C1522577
Beschreibung
Administative data
Alias
- UMLS CUI-1
- C1320722
Ähnliche Modelle
Sample Case Report Form: Laboratory Reference Ranges and Serious Adverse Events
C0805701 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
C0011008 (UMLS CUI [1,2])
C1514721 (UMLS CUI [1,2])
C0439148 (UMLS CUI [1,2])
C1522609 (UMLS CUI [1,2])
C0205251 (UMLS CUI [1,3])
C1522609 (UMLS CUI [1,2])
C0205250 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,2])
C0237753 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C0085978 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,3])
C1386497 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,3])
C1519255 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C0011298 (UMLS CUI-2)
C0034897 (UMLS CUI [1,2])
C0085978 (UMLS CUI-2)
C0085978 (UMLS CUI [1,2])
C0262926 (UMLS CUI-2)
C1519255 (UMLS CUI-3)
C0020517 (UMLS CUI [2])
C0543467 (UMLS CUI [3])
C0012634 (UMLS CUI [1,2])
C1519255 (UMLS CUI [2])
C0011008 (UMLS CUI [1,2])
C2745955 (UMLS CUI [1,3])
C0035648 (UMLS CUI-2)
C1519255 (UMLS CUI [1,2])
C2347852 (UMLS CUI-2)
C2347852 (UMLS CUI [1,2])
C2347852 (UMLS CUI [1,2])
C2347852 (UMLS CUI [1,2])
C2347852 (UMLS CUI [1,2])
C0013230 (UMLS CUI-2)
C1522508 (UMLS CUI-3)
C0042210 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,2])
C1515974 (UMLS CUI [2])
C0011008 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,3])
C0443289 (UMLS CUI [1,2])
C0220825 (UMLS CUI-2)
C1261322 (UMLS CUI [1,2])
C1522508 (UMLS CUI [1,3])
C0947611 (UMLS CUI-2)
C1519255 (UMLS CUI [1,2])
C1533716 (UMLS CUI-2)
C1519255 (UMLS CUI-3)
C1522577 (UMLS CUI-4)
C1533716 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,3])
C1522577 (UMLS CUI [1,4])
C0011008 (UMLS CUI [1,2])