Engels

Pharmacogenetics Research Consent Form

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Administrative data
Beschrijving

Administrative data

Site
Beschrijving

Site

Datatype

text

Patient
Beschrijving

Patient

Datatype

text

Patient Number
Beschrijving

Patient Number

Datatype

integer

Date of Visit/Assessment
Beschrijving

Date of Visit/Assessment

Datatype

date

Date of Visit/Assessment
Beschrijving

Date of Visit/Assessment

Date
Beschrijving

Date

Datatype

date

PGx Research Consent
Beschrijving

PGx Research Consent

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

Has informed consent been obtained for PGx-Pharmacogenetic research?

Datatype

boolean

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

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

Datatype

date

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

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

Datatype

boolean

If YES, record date sample taken
Beschrijving

If YES, record date sample taken

Datatype

date

If NO informed consent obtained, check reason
Beschrijving

If NO informed consent obtained, check reason

Datatype

text

If Other, specify
Beschrijving

If Other, specify

Datatype

text

Genetics Type
Beschrijving

Genetics Type

Datatype

text

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Similar models

Pharmacogenetics Research Consent Form

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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