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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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Similar models

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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