Treatment blind broken during study
Item
Was the treatment blind broken during study? If yes, complete the Adverse Event form and/ or Investigational Product forms as appropriate.
boolean
C0749659 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
C1709750 (UMLS CUI [1,3])
Date and time of blind broken
Item
If the treatment blind was broken during the study, record date and time of blind broken.
datetime
C0749659 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
C1709750 (UMLS CUI [1,3])
C1264639 (UMLS CUI [1,4])
Item
If the Treatment blind was broken during the study, record reason.
integer
C0749659 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
C1709750 (UMLS CUI [1,3])
C0566251 (UMLS CUI [1,4])
Code List
If the Treatment blind was broken during the study, record reason.
CL Item
Medical emergency requiring identification of investigational product for further treatment (1)
CL Item
Other, specify (2)
Other reason blind broken
Item
Other reason blind broken
text
C0749659 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
C1709750 (UMLS CUI [1,3])
C0566251 (UMLS CUI [1,4])
C0205394 (UMLS CUI [1,5])
Actual Time
Item
Actual time
time
C0040223 (UMLS CUI [1])
Blood Pressure
Item
Blood pressure (systolic/ diastolic)
text
C0005823 (UMLS CUI [1])
heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Time of ECG
Item
Time of ECG
time
C0013798 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Electrocardiogram: P-R interval
Item
PR Interval
float
C0429087 (UMLS CUI [1])
QRS complex duration (observable entity)
Item
QRS Duration
float
C0429025 (UMLS CUI [1])
QT interval - finding
Item
Uncorrected QT Interval
float
C1287082 (UMLS CUI [1])
Item
Method of QTc Calculation
integer
C0855331 (UMLS CUI [1,1])
C2911685 (UMLS CUI [1,2])
Code List
Method of QTc Calculation
CL Item
Machine; record QTc value(s) generated by the machine (1)
CL Item
Manual; record the RR interval that precedes the measured QT interval (2)
Item
If QTc interval was calculated mechanical, check method of caluclation
text
C0855331 (UMLS CUI [1,1])
C2911685 (UMLS CUI [1,2])
C0443254 (UMLS CUI [1,3])
Code List
If QTc interval was calculated mechanical, check method of caluclation
CL Item
QTcB (Bazett) (B)
CL Item
QTcF (Fridericia) (F)
QTcB - Bazett's Correction Formula; Mechanical Methods
Item
If QTc interval was calculated mechanically with Bazett's formula, enter finding.
float
C1882512 (UMLS CUI [1,1])
C0443254 (UMLS CUI [1,2])
QTcF - Fridericia's Correction Formula; Mechanical Methods; Finding
Item
If QTc interval was calculated mechanically with Fridericia's formula, enter finding.
float
C1882513 (UMLS CUI [1,1])
C0443254 (UMLS CUI [1,2])
C0243095 (UMLS CUI [1,3])
Item
If QTc interval was calcualted manually, check method of caluclation.
text
C0855331 (UMLS CUI [1,1])
C2911685 (UMLS CUI [1,2])
C0175674 (UMLS CUI [1,3])
Code List
If QTc interval was calcualted manually, check method of caluclation.
CL Item
RR interval not available (NA)
Electrocardiogram QT corrected interval; Manual; Finding
Item
If QTc interval was calculated manually with RR interval, enter finding.
float
C0855331 (UMLS CUI [1,1])
C0175674 (UMLS CUI [1,2])
C0243095 (UMLS CUI [1,3])
Item
Result of ECG
integer
C0438154 (UMLS CUI [1])
CL Item
Abnormal - Not clinically significant (2)
CL Item
Abnormal - Clinically significant (complete the ECG abnormality form for all significant abnormalities, and additionally complete the AE form if the abnormality meets the protocol definition for an AE) (3)
CL Item
No result (not available) (4)
Date of last contact
Item
Date of last contact
date
C0805839 (UMLS CUI [1])
Was the subject withdrawn from the study
Item
Was the subject withdrawn from the study?
boolean
C0422727 (UMLS CUI [1])
Date of decision to withdraw
Item
If subject was withdrawn from study, record date of decision to withdraw.
date
C0422727 (UMLS CUI [1,1])
C0679006 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
If subjects was withdrawn from study, check reason for withdrawal.
integer
C0422727 (UMLS CUI [1,1])
C3146298 (UMLS CUI [1,2])
Code List
If subjects was withdrawn from study, check reason for withdrawal.
CL Item
Adverse Event (Record details on the Non- Serious Adverse Events or Serious Adverse Events forms as appropriate) (1)
CL Item
Protocol deviation (3)
CL Item
Study closed/ terminated (5)
CL Item
Lost to Follow- up (6)
CL Item
Withdrew consent (8)
Item
Case book ready for signature
text
C1519316 (UMLS CUI [1])
Code List
Case book ready for signature
Did the subject become pregnant during the study?
Item
Did the subject become pregnant during the study?
boolean
Item
Did a female partner of the male subject become pregnant during the study?
text
Code List
Did a female partner of the male subject become pregnant during the study?
CL Item
Not Applicable (Check Not Applicable if female partner not of childbearing potential or no female partner) (X)
Hematology Date and time sample taken
Item
Hematology Date and time sample taken
datetime
C0018943 (UMLS CUI [1,1])
C0200345 (UMLS CUI [1,2])
C1264639 (UMLS CUI [1,3])
Clinical Chemistry Date and time sample taken
Item
Clinical Chemistry Date and time sample taken
datetime
C0008000 (UMLS CUI [1,1])
C0200345 (UMLS CUI [1,2])
C1264639 (UMLS CUI [1,3])
Urinalysis Date and time sample taken
Item
Urinalysis Date and time sample taken
datetime
C0042014 (UMLS CUI [1,1])
C0200345 (UMLS CUI [1,2])
C1264639 (UMLS CUI [1,3])