Patient ID; Centre Number
Item
Patient ID, Centre No.
text
C1269815 (UMLS CUI [1,1])
C2825181 (UMLS CUI [1,2])
C1300638 (UMLS CUI [1,3])
Patient ID; Envelope Number
Item
Patient ID, Envelope No.
text
C1269815 (UMLS CUI [1,1])
C2348585 (UMLS CUI [1,2])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Item
Was the study drug unblinded at any time during the study?
text
C0304229 (UMLS CUI [1,1])
C3897431 (UMLS CUI [1,2])
Code List
Was the study drug unblinded at any time during the study?
CL Item
Yes (Specify) (Yes (Specify))
Item
Did patient withdraw consent during the study?
text
C1707492 (UMLS CUI [1])
Code List
Did patient withdraw consent during the study?
CL Item
Yes (give date) (Yes (give date))
Comment
Item
Additional comments
text
C0947611 (UMLS CUI [1])
Investigator's signature
Item
Investigator's signature
text
C2346576 (UMLS CUI [1])
investigator last name
Item
Please print investigator last name in block capitals
text
C0008961 (UMLS CUI [1,1])
C1301584 (UMLS CUI [1,2])
Investigator signature, date
Item
Date of signature
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])