Engels

End of study, Investigator Comment Log, Investigator’s Statement

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Administrative data
Beschrijving

Administrative data

Alias
UMLS CUI-1
C1320722
Subject Number
Beschrijving

Subject Number

Datatype

text

Alias
UMLS CUI [1]
C2348585
Session Number
Beschrijving

Session Number

Datatype

integer

Alias
UMLS CUI [1,1]
C1883017
UMLS CUI [1,2]
C0750480
End of Study Record
Beschrijving

End of Study Record

Alias
UMLS CUI-1
C0008976
UMLS CUI-2
C0444930
Date of subject completion or discontinuation from the study
Beschrijving

day month year. Check that the "Date of subject completion or discontinuation from the study" is on or after the last treatment stop date on the INVESTIGATIONAL PRODUCT page.

Datatype

date

Alias
UMLS CUI [1,1]
C2348577
UMLS CUI [1,2]
C0011008
UMLS CUI [2,1]
C0457454
UMLS CUI [2,2]
C0008976
UMLS CUI [2,3]
C0011008
Time of subject completion or discontinuation from the study
Beschrijving

00:00-23:59. Check that the "Time of subject completion or discontinuation from the study" is the same as or after the time of last treatment dose (if applicable) on the INVEST/GA TIONAL PRODUCT page if present.

Datatype

time

Alias
UMLS CUI [1,1]
C2348577
UMLS CUI [1,2]
C0040223
UMLS CUI [2,1]
C0457454
UMLS CUI [2,2]
C0040223
Did the subject become pregnant during the study?
Beschrijving

Tick one. This question must be answered for all subjects. For females not of childbearing potential or males, tick NOT APPLICABLE. If no pregnancy was known before a subject was lost to follow-up, tick NO. If the subject became pregnant before either premature discontinuation from the study or completion of the study, tick YES. If you tick YES, record details on PREGNANCY NOTIFICATION FORM.

Datatype

text

Alias
UMLS CUI [1]
C0032961
Did the subject experience an incident or near incident with GlaxoSmithKline medical devices provided for use during the study?
Beschrijving

The medical devices being used in this study are the VOLUMATIC spacers. If a subject never used this/these device(s), tick NO. If no incident was known before a subject was lost to follow-up, tick NO. If an incident occurred before either premature discontinuation from the study or completion of the study, tick YES. If you tick YES, record details on the MEDICAL DEVICE INCIDENT REPORT FORM.

Datatype

text

Alias
UMLS CUI [1,1]
C0025080
UMLS CUI [1,2]
C1551358
Did the subject discontinue the study prematurely?
Beschrijving

Subjects who complete all study visits (screening, all treatment periods and follow-up) will be considered as having completed the study.

Datatype

text

Alias
UMLS CUI [1,1]
C0457454
UMLS CUI [1,2]
C0008976
If you tick yes in "Discontinuation of study", tick the primary reason for discontinuation.
Beschrijving

Tick one. If A: Record details on NON-SERIOUS ADVERSE EVENTS or SERIOUS ADVERSE EVENT page as appropriate.

Datatype

text

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0457454
UMLS CUI [1,3]
C0008976
If other reason, please specify
Beschrijving

Other reason

Datatype

text

Alias
UMLS CUI [1]
C3840932
Investigator Comment Log
Beschrijving

Investigator Comment Log

Alias
UMLS CUI-1
C0008961
UMLS CUI-2
C0947611
Date of comment
Beschrijving

Date of comment

Datatype

date

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C0011008
CRF page number if applicable
Beschrijving

CRF page number

Datatype

integer

Alias
UMLS CUI [1,1]
C1704732
UMLS CUI [1,2]
C1516308
Comment
Beschrijving

Comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
Investigator’s Statement
Beschrijving

Investigator’s Statement

Alias
UMLS CUI-1
C0008961
UMLS CUI-2
C1710187
Confirmation
Beschrijving

I confirm that I have carefully examined all entries on the Screening Case Report Form for this subject. All information entered by myself or my colleagues is, to the best of my knowledge, correct as of the date below.

Datatype

boolean

Alias
UMLS CUI [1]
C0750484
Date
Beschrijving

day month year

Datatype

date

Alias
UMLS CUI [1]
C0011008
Investigator’s signature
Beschrijving

Investigator’s signature

Datatype

text

Alias
UMLS CUI [1]
C2346576
Investigator’s name - print
Beschrijving

Investigator’s name - print

Datatype

text

Alias
UMLS CUI [1]
C2826892
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Similar models

End of study, Investigator Comment Log, Investigator’s Statement

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Subject Number
Item
Subject Number
text
C2348585 (UMLS CUI [1])
Item
Session Number
integer
C1883017 (UMLS CUI [1,1])
C0750480 (UMLS CUI [1,2])
Session Number
Code List
Session Number
CL Item
Session 1 (1)
CL Item
Session 2 (2)
CL Item
Session 3 (3)
CL Item
Session 4 (4)
CL Item
Session 5 (5)
CL Item
Session 6 (6)
Item Group
End of Study Record
C0008976 (UMLS CUI-1)
C0444930 (UMLS CUI-2)
Date of subject completion or discontinuation from the study
Item
Date of subject completion or discontinuation from the study
date
C2348577 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0457454 (UMLS CUI [2,1])
C0008976 (UMLS CUI [2,2])
C0011008 (UMLS CUI [2,3])
Time of subject completion or discontinuation from the study
Item
Time of subject completion or discontinuation from the study
time
C2348577 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
C0457454 (UMLS CUI [2,1])
C0040223 (UMLS CUI [2,2])
Item
Did the subject become pregnant during the study?
text
C0032961 (UMLS CUI [1])
Pregnancy
Code List
Did the subject become pregnant during the study?
CL Item
Not applicable (Not of childbearing potential or male) (X)
CL Item
Yes  (Y)
CL Item
No (N)
Item
Did the subject experience an incident or near incident with GlaxoSmithKline medical devices provided for use during the study?
text
C0025080 (UMLS CUI [1,1])
C1551358 (UMLS CUI [1,2])
Incident or near incident with GlaxoSmithKline medical devices
Code List
Did the subject experience an incident or near incident with GlaxoSmithKline medical devices provided for use during the study?
CL Item
Yes (Y)
CL Item
No (N)
Item
Did the subject discontinue the study prematurely?
text
C0457454 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
Discontinuation of study
Code List
Did the subject discontinue the study prematurely?
CL Item
Yes (Y)
CL Item
No (N)
Item
If you tick yes in "Discontinuation of study", tick the primary reason for discontinuation.
text
C0392360 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
Discontinuation of study, reason
Code List
If you tick yes in "Discontinuation of study", tick the primary reason for discontinuation.
CL Item
Adverse event (A)
CL Item
Consent withdrawn (C)
CL Item
Lost to follow up (L)
CL Item
Protocol violation (P)
CL Item
Other (X)
Other reason
Item
If other reason, please specify
text
C3840932 (UMLS CUI [1])
Item Group
Investigator Comment Log
C0008961 (UMLS CUI-1)
C0947611 (UMLS CUI-2)
Date of comment
Item
Date of comment
date
C0947611 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
CRF page number
Item
CRF page number if applicable
integer
C1704732 (UMLS CUI [1,1])
C1516308 (UMLS CUI [1,2])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Item Group
Investigator’s Statement
C0008961 (UMLS CUI-1)
C1710187 (UMLS CUI-2)
Confirmation
Item
Confirmation
boolean
C0750484 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Investigator’s signature
Item
Investigator’s signature
text
C2346576 (UMLS CUI [1])
Investigator’s name - print
Item
Investigator’s name - print
text
C2826892 (UMLS CUI [1])
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