Informed Consent and Demographics
Informed Consent Date
date
Center Number
integer
Date of birth
date
Gender
text
Race
integer
Geographical area
integer
Eligibility Check
Do not enter the subject into the study if he/she failed any inclusion or exclusion criteria below.
integer
Inclusion criteria
integer
Exclusion Criteria
integer
Screening conclusion
Serious Adverse Event
integer
Number of SAEs
integer
Screening failure
boolean
Screening failure
integer
Decision maker
integer
Administative data
I confirm that I have reviewed the data in these screening forms 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.
text
Date
date
Printed name
text