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Study conclusion

1 Formulär  
  1. StudyEvent: ODM
    1. Study conclusion
Administrative data
Beskrivning

Administrative data

Alias
UMLS CUI-1
C1320722
Subject number
Beskrivning

Subject number

Datatyp

text

Alias
UMLS CUI [1]
C2348585
Workbook number
Beskrivning

Workbook number

Datatyp

integer

Alias
UMLS CUI [1]
C2986015
Date of study conclusion
Beskrivning

Date of study conclusion

Datatyp

date

Alias
UMLS CUI [1,1]
C1707478
UMLS CUI [1,2]
C0008972
UMLS CUI [1,3]
C0011008
STUDY CONCLUSION: OCCURRENCE OF SERIOUS ADVERSE EVENT
Beskrivning

STUDY CONCLUSION: OCCURRENCE OF SERIOUS ADVERSE EVENT

Alias
UMLS CUI-1
C1707478
UMLS CUI-2
C0008972
UMLS CUI-3
C1519255
Did the subject experience any Serious Adverse Event during the study?
Beskrivning

Serious Adverse Event during study

Datatyp

text

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0347984
UMLS CUI [1,3]
C0008972
If Serious Adverse Event during the study occured, please specify total number of SAE's
Beskrivning

Total number of SAE's

Datatyp

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C1519255
STATUS OF TREATMENT BLIND
Beskrivning

STATUS OF TREATMENT BLIND

Alias
UMLS CUI-1
C0749659
UMLS CUI-2
C2347038
Was the treatment blind broken during the study?
Beskrivning

Complete Serious Adverse Event report as appropriate. For workbook 2 you can also complete Non-Serious Adverse Event section as appropriate.

Datatyp

text

Alias
UMLS CUI [1,1]
C0749659
UMLS CUI [1,2]
C2347038
If treatment was blind broken, complete the date
Beskrivning

Treatment blind broken, date

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0749659
UMLS CUI [1,3]
C2347038
Treatment blind broken, reason
Beskrivning

Treatment blind broken, reason

Datatyp

integer

Alias
UMLS CUI [1,1]
C0749659
UMLS CUI [1,2]
C2347038
UMLS CUI [1,3]
C0566251
If other reason for treatment blind broken, please specify
Beskrivning

Other reason for treatment blind broken

Datatyp

text

Alias
UMLS CUI [1,1]
C0749659
UMLS CUI [1,2]
C2347038
UMLS CUI [1,3]
C0205394
UMLS CUI [1,4]
C0566251
ELIMINATION CRITERIA
Beskrivning

ELIMINATION CRITERIA

Alias
UMLS CUI-1
C0680251
Did any elimination criteria become applicable since last visit?
Beskrivning

Please tick all that applies in following items.

Datatyp

text

Alias
UMLS CUI [1,1]
C0680251
UMLS CUI [1,2]
C1706839
Chronic administration of immunosuppressants or other immune-modifying drugs.
Beskrivning

Chronic administration is defined as more than 14 days

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0680251
UMLS CUI [1,2]
C0021081
UMLS CUI [1,3]
C0205191
UMLS CUI [1,4]
C0005525
Major congenital defects or serious chronic illness.
Beskrivning

Elimination criteria: Major congenital defects/serious chronic illness.

Datatyp

boolean

Alias
UMLS CUI [1]
C0680251
UMLS CUI [2,1]
C0220810
UMLS CUI [2,2]
C0205164
UMLS CUI [3,1]
C0008679
UMLS CUI [3,2]
C0205404
Any confirmed or suspected immunosuppressive or immunodeficient condition.
Beskrivning

Elimination criteria: confirmed/suspected immunosuppressive/immunodeficient condition.

Datatyp

boolean

Alias
UMLS CUI [1]
C0680251
UMLS CUI [2,1]
C0750484
UMLS CUI [2,2]
C3829792
UMLS CUI [3,1]
C0750484
UMLS CUI [3,2]
C4048329
UMLS CUI [4,1]
C0242114
UMLS CUI [4,2]
C3829792
UMLS CUI [5,1]
C0242114
UMLS CUI [5,2]
C4048329
Administration of immunoglobulins and/or any blood derived products.
Beskrivning

Elimination criteria: immunoglobulins/any blood derived products

Datatyp

boolean

Alias
UMLS CUI [1]
C0680251
UMLS CUI [2]
C0021027
UMLS CUI [3]
C0456388
Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s).
Beskrivning

Elimination criteria: use of investigational or non-registered product

Datatyp

boolean

Alias
UMLS CUI [1]
C0680251
UMLS CUI [2,1]
C0304229
UMLS CUI [2,2]
C0042210
UMLS CUI [2,3]
C1444655
UMLS CUI [2,4]
C2348563
Withdrawing from study
Beskrivning

Withdrawing from study

Alias
UMLS CUI-1
C0422727
Was the subject withdrawn from the study?
Beskrivning

If yes, note major reason. Therefore tick one of the following items

Datatyp

text

Reason for withdrawal
Beskrivning

If you tick SAE, please complete and submit SAE report. If you tick AEX, please complete Non-serious Adverse Event section.

Datatyp

text

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C0392360
UMLS CUI [1,3]
C0008976
If SAE, please specify SAE Number
Beskrivning

Please complete and submit SAE report

Datatyp

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0237753
If AEX, please specify AE Number
Beskrivning

Please complete Non-serious Adverse Event section

Datatyp

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0237753
If AEX, please specify solicited AE Code
Beskrivning

In workbook 1 and 2 only for immuno and reato subset.

Datatyp

integer

Alias
UMLS CUI [1,1]
C0683368
UMLS CUI [1,2]
C1517001
UMLS CUI [1,3]
C1518404
UMLS CUI [1,4]
C0805701
If protocol violation, please specify
Beskrivning

Protocol violation

Datatyp

text

Alias
UMLS CUI [1]
C1709750
If other reason for withdrawal, please specify
Beskrivning

Withdrawal, other reason

Datatyp

text

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C3840932
Who made the decision
Beskrivning

Dicision made by

Datatyp

text

Alias
UMLS CUI [1]
C0679006
Date of last contact
Beskrivning

Date of last contact

Datatyp

date

Alias
UMLS CUI [1]
C0805839
Was the subject in good condition at date of last contact
Beskrivning

If you tick No, please give details in Adverse Events section.

Datatyp

text

Alias
UMLS CUI [1,1]
C0805839
UMLS CUI [1,2]
C1142435
INVESTIGATOR'S SIGNATURE
Beskrivning

INVESTIGATOR'S SIGNATURE

Alias
UMLS CUI-1
C2346576
Investigator's signature
Beskrivning

Investigator's signature

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Date of signature
Beskrivning

Date of signature

Datatyp

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Printed Investigator's name
Beskrivning

Printed Investigator's name

Datatyp

text

Alias
UMLS CUI [1]
C2826892
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Similar models

Study conclusion

1 Formulär
  1. StudyEvent: ODM
    1. Study conclusion
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Subject number
Item
Subject number
text
C2348585 (UMLS CUI [1])
Item
Workbook number
integer
C2986015 (UMLS CUI [1])
Workbook number
Code List
Workbook number
CL Item
workbook 1 (1)
CL Item
workbook 2 (2)
CL Item
workbook 3 (3)
Date of study conclusion
Item
Date of study conclusion
date
C1707478 (UMLS CUI [1,1])
C0008972 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item Group
STUDY CONCLUSION: OCCURRENCE OF SERIOUS ADVERSE EVENT
C1707478 (UMLS CUI-1)
C0008972 (UMLS CUI-2)
C1519255 (UMLS CUI-3)
Item
Did the subject experience any Serious Adverse Event during the study?
text
C1519255 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C0008972 (UMLS CUI [1,3])
Serious Adverse Event during study
Code List
Did the subject experience any Serious Adverse Event during the study?
CL Item
No (N)
CL Item
Yes (Y)
Total number of SAE's
Item
If Serious Adverse Event during the study occured, please specify total number of SAE's
integer
C0449788 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item Group
STATUS OF TREATMENT BLIND
C0749659 (UMLS CUI-1)
C2347038 (UMLS CUI-2)
Item
Was the treatment blind broken during the study?
text
C0749659 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
Treatment blind broken
Code List
Was the treatment blind broken during the study?
CL Item
No  (N)
CL Item
Yes (Y)
Treatment blind broken, date
Item
If treatment was blind broken, complete the date
date
C0011008 (UMLS CUI [1,1])
C0749659 (UMLS CUI [1,2])
C2347038 (UMLS CUI [1,3])
Item
Treatment blind broken, reason
integer
C0749659 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
Treatment blind broken, reason
Code List
Treatment blind broken, reason
CL Item
Medical emergency requiring identification of investigational product for further treatments (1)
CL Item
Other (9)
Other reason for treatment blind broken
Item
If other reason for treatment blind broken, please specify
text
C0749659 (UMLS CUI [1,1])
C2347038 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C0566251 (UMLS CUI [1,4])
Item Group
ELIMINATION CRITERIA
C0680251 (UMLS CUI-1)
Item
Did any elimination criteria become applicable since last visit?
text
C0680251 (UMLS CUI [1,1])
C1706839 (UMLS CUI [1,2])
Elimination criteria become applicable
Code List
Did any elimination criteria become applicable since last visit?
CL Item
No (N)
CL Item
Yes (Y)
Elimination criteria: immunosuppressants/immune-modifying drugs
Item
Chronic administration of immunosuppressants or other immune-modifying drugs.
boolean
C0680251 (UMLS CUI [1,1])
C0021081 (UMLS CUI [1,2])
C0205191 (UMLS CUI [1,3])
C0005525 (UMLS CUI [1,4])
Elimination criteria: Major congenital defects/serious chronic illness.
Item
Major congenital defects or serious chronic illness.
boolean
C0680251 (UMLS CUI [1])
C0220810 (UMLS CUI [2,1])
C0205164 (UMLS CUI [2,2])
C0008679 (UMLS CUI [3,1])
C0205404 (UMLS CUI [3,2])
Elimination criteria: confirmed/suspected immunosuppressive/immunodeficient condition.
Item
Any confirmed or suspected immunosuppressive or immunodeficient condition.
boolean
C0680251 (UMLS CUI [1])
C0750484 (UMLS CUI [2,1])
C3829792 (UMLS CUI [2,2])
C0750484 (UMLS CUI [3,1])
C4048329 (UMLS CUI [3,2])
C0242114 (UMLS CUI [4,1])
C3829792 (UMLS CUI [4,2])
C0242114 (UMLS CUI [5,1])
C4048329 (UMLS CUI [5,2])
Elimination criteria: immunoglobulins/any blood derived products
Item
Administration of immunoglobulins and/or any blood derived products.
boolean
C0680251 (UMLS CUI [1])
C0021027 (UMLS CUI [2])
C0456388 (UMLS CUI [3])
Elimination criteria: use of investigational or non-registered product
Item
Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s).
boolean
C0680251 (UMLS CUI [1])
C0304229 (UMLS CUI [2,1])
C0042210 (UMLS CUI [2,2])
C1444655 (UMLS CUI [2,3])
C2348563 (UMLS CUI [2,4])
Item Group
Withdrawing from study
C0422727 (UMLS CUI-1)
Item
Was the subject withdrawn from the study?
text
Withdrawal from study
Code List
Was the subject withdrawn from the study?
CL Item
No (N)
CL Item
Yes (Y)
Item
Reason for withdrawal
text
C2349954 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
Reason for withdrawal
Code List
Reason for withdrawal
CL Item
Serious adverse event (SAE)
CL Item
Non-Serious adverse event (AEX)
CL Item
Protocol violation (PTV)
CL Item
Consent withdrawal, not due to an adverse event (CWS)
CL Item
Migrated / moved from the study area (MIG)
CL Item
Lost to follow-up (LFU)
CL Item
Other (OTH)
SAE Number
Item
If SAE, please specify SAE Number
integer
C1519255 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
AE Number
Item
If AEX, please specify AE Number
integer
C1518404 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Solicited AE Code
Item
If AEX, please specify solicited AE Code
integer
C0683368 (UMLS CUI [1,1])
C1517001 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
C0805701 (UMLS CUI [1,4])
Protocol violation
Item
If protocol violation, please specify
text
C1709750 (UMLS CUI [1])
Withdrawal, other reason
Item
If other reason for withdrawal, please specify
text
C2349954 (UMLS CUI [1,1])
C3840932 (UMLS CUI [1,2])
Item
Who made the decision
text
C0679006 (UMLS CUI [1])
Dicision made by
Code List
Who made the decision
CL Item
Investigator  (I)
CL Item
Parents/Guardians (P)
Date of last contact
Item
Date of last contact
date
C0805839 (UMLS CUI [1])
Item
Was the subject in good condition at date of last contact
text
C0805839 (UMLS CUI [1,1])
C1142435 (UMLS CUI [1,2])
Condition at date of last contact
Code List
Was the subject in good condition at date of last contact
CL Item
No (N)
CL Item
Yes (Y)
Item Group
INVESTIGATOR'S SIGNATURE
C2346576 (UMLS CUI-1)
Investigator's signature
Item
Investigator's signature
text
C2346576 (UMLS CUI [1])
Date of signature
Item
Date of signature
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Printed Investigator's name
Item
Printed Investigator's name
text
C2826892 (UMLS CUI [1])
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