0 Ratings
ID

32645

Description

Study ID: 106904 Clinical Study ID: CRV106904 Study Title: A Randomized, Open-Label, Single-Dose, Four-Period Cross-Over Study to Determine the Effects of Alcohol on the Pharmacokinetics of Carvedilol CR Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier:  Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 1 Study Recruitment Status: Completed Generic Name: carvedilol Trade Name: Coreg CR,Coreg Study Indication: Hypertension

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Versions (2)
  1. 11/9/18 11/9/18 -
  2. 1/11/19 1/11/19 -
Copyright Holder

GSK group of companies

Uploaded on

November 9, 2018

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License

Creative Commons BY-NC 3.0
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    A Cross-Over Study of Alcohol Effect on the Pharmacokinetics of Carvedilol - 106904

    English

    Pharmacogenetics Research Consent Form

    1 forms  
    Administrative data
    Description

    Administrative data

    Site
    Description

    Site

    Data type

    text

    Patient
    Description

    Patient

    Data type

    text

    Patient Number
    Description

    Patient Number

    Data type

    integer

    Date of Visit/Assessment
    Description

    Date of Visit/Assessment

    Data type

    date

    Date of Visit/Assessment
    Description

    Date of Visit/Assessment

    Date
    Description

    Date

    Data type

    date

    PGx Research Consent
    Description

    PGx Research Consent

    Has informed consent been obtained for PGx-Pharmacogenetic research?
    Description

    Has informed consent been obtained for PGx-Pharmacogenetic research?

    Data type

    boolean

    If YES, record date informed consent obtained for PGx-Pharmacogenetic research
    Description

    If YES, record date informed consent obtained for PGx-Pharmacogenetic research

    Data type

    date

    Has a blood sample been collected for PGx-Pharmacogenetic (DNA) research
    Description

    Has a blood sample been collected for PGx-Pharmacogenetic (DNA) research

    Data type

    boolean

    If YES, record date sample taken
    Description

    If YES, record date sample taken

    Data type

    date

    If NO informed consent obtained, check reason
    Description

    If NO informed consent obtained, check reason

    Data type

    text

    If Other, specify
    Description

    If Other, specify

    Data type

    text

    Genetics Type
    Description

    Genetics Type

    Data type

    text

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    Pharmacogenetics Research Consent Form

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Administrative data
    Site
    Item
    Site
    text
    Patient
    Item
    Patient
    text
    Patient Number
    Item
    Patient Number
    integer
    Date of Visit/Assessment
    Item
    Date of Visit/Assessment
    date
    Item Group
    Date of Visit/Assessment
    Date
    Item
    Date
    date
    Item Group
    PGx Research Consent
    Has informed consent been obtained for PGx-Pharmacogenetic research?
    Item
    Has informed consent been obtained for PGx-Pharmacogenetic research?
    boolean
    If YES, record date informed consent obtained for PGx-Pharmacogenetic research
    Item
    If YES, record date informed consent obtained for PGx-Pharmacogenetic research
    date
    Has a blood sample been collected for PGx-Pharmacogenetic (DNA) research
    Item
    Has a blood sample been collected for PGx-Pharmacogenetic (DNA) research
    boolean
    If YES, record date sample taken
    Item
    If YES, record date sample taken
    date
    Item
    If NO informed consent obtained, check reason
    text
    If NO informed consent obtained, check reason
    Code List
    If NO informed consent obtained, check reason
    CL Item
    Subject declined (1)
    CL Item
    Subject not asked by Investigator (2)
    CL Item
    Other (3)
    If Other, specify
    Item
    If Other, specify
    text
    Genetics Type
    Item
    Genetics Type
    text
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