ID

33067

Descrição

Study ID: 104020 Clinical Study ID: 104020 Study Title: Blinded, randomised study to assess the immunogenicity and safety of GlaxoSmithKline (GSK) Biologicals’ live attenuated measles-mumps-rubella-varicella candidate vaccine when given to healthy children in their second year of life Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00126997 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 4 Study Recruitment Status: Completed Generic Name: Combined Measles, Mumps, Rubella, Varicella Vaccine Trade Name: Priorix Tetra Study Indication: Measles; Mumps; Rubella; Varicella CRF Seiten: 268-336; 870-938

Palavras-chave

Versões (2)
  1. 23/11/2018 23/11/2018 -
  2. 26/11/2018 26/11/2018 -
Titular dos direitos

GSK group of companies

Transferido a

26 de novembro de 2018

DOI

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Licença

Creative Commons BY-NC 3.0
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Immunogenicity of Combined Measles Mumps Rubella Varicella Vaccine for healthy 2 y.o children - 104020

Inglês

Visit 2: Vaccine Administration

1 Formulários  
Administrative data
Descrição

Administrative data

Visit Number
Descrição

Visit Number

Tipo de dados

text

Date of Visit
Descrição

Date of Visit

Tipo de dados

date

Subject Number
Descrição

Subject Number

Tipo de dados

integer

Vaccine Administration
Descrição

Vaccine Administration

Date
Descrição

Date

Tipo de dados

date

Pre-Vaccination temperature
Descrição

Pre-Vaccination temperature

Tipo de dados

float

Unidades de medida
  • °C
°C
Route
Descrição

Route

Tipo de dados

text

Vaccine
Descrição

Vaccine

Only ONE box must be ticked by vaccine
Descrição

Only ONE box must be ticked by vaccine

Tipo de dados

text

if Replacement vial, record number
Descrição

if Replacement vial, record number

Tipo de dados

integer

If Wrong vial number, please record the correct one
Descrição

If Wrong vial number, please record the correct one

Tipo de dados

integer

Side/ Site/ Route
Descrição

Side/ Site/ Route

Side of injection
Descrição

Side of injection

Tipo de dados

text

Site of injection
Descrição

Site of injection

Tipo de dados

text

Route of injection
Descrição

Route of injection

Tipo de dados

text

Administration according to Protocol
Descrição

Administration according to Protocol

Has the study vaccine been administered according to protocol?
Descrição

If any adverse event soccurred during the immediate post-vaccination time (30 min) please fill in the Solicited Adverse Events section, the Non-Serious Adverse Event section or a SAE form. If any prophylactic medication has been administered -> Medication Form; If any other vaccines administered -> Concomitant Vaccination form.

Tipo de dados

boolean

If No, please tick all items that apply: Side
Descrição

If No, please tick all items that apply: Side

Tipo de dados

integer

Site
Descrição

Site

Tipo de dados

text

Route
Descrição

Route

Tipo de dados

text

Comment
Descrição

Comment

Tipo de dados

text

Non-administration
Descrição

Non-administration

Please tick ONE most appropriate category for non administration
Descrição

Please tick ONE most appropriate category for non administration

Tipo de dados

text

If SAE, specify SAE Number
Descrição

If SAE, specify SAE Number

Tipo de dados

integer

If Non-SAE, please specify unsolicited AE Number
Descrição

If Non-SAE, please specify unsolicited AE Number

Tipo de dados

integer

If Other, please specify
Descrição

e.g., consent withdrawal, protocol violation, etc

Tipo de dados

text

Please tick who took the decision
Descrição

Please tick who took the decision

Tipo de dados

text

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Similar models

Visit 2: Vaccine Administration

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Administrative data
Item
Visit Number
text
Visit Number
Code List
Visit Number
CL Item
Visit 2 (1)
Date of Visit
Item
Date of Visit
date
Subject Number
Item
Subject Number
integer
Item Group
Vaccine Administration
Date
Item
Date
date
Pre-Vaccination temperature
Item
Pre-Vaccination temperature
float
Item
Route
text
Route
Code List
Route
CL Item
Axillary (1)
CL Item
Rectal (2)
Item Group
Vaccine
Item
Only ONE box must be ticked by vaccine
text
Only one box must be ticked by vaccine
Code List
Only ONE box must be ticked by vaccine
CL Item
MeMuRu-OKA Vaccine  (1)
CL Item
Replacement vial (2)
CL Item
Wrong vial number (3)
CL Item
Not administered (4)
if Replacement vial, record number
Item
if Replacement vial, record number
integer
If Wrong vial number, please record the correct one
Item
If Wrong vial number, please record the correct one
integer
Item Group
Side/ Site/ Route
Item
Side of injection
text
Site of injection
Code List
Side of injection
CL Item
Left Upper arm (1)
Item
Site of injection
text
Site of injection
Code List
Site of injection
CL Item
Deltoid region  (1)
Item
Route of injection
text
Route of injection
Code List
Route of injection
CL Item
S.C. (1)
Item Group
Administration according to Protocol
Has the study vaccine been administered according to protocol?
Item
Has the study vaccine been administered according to protocol?
boolean
Item
If No, please tick all items that apply: Side
integer
If No, please tick all items that apply: Side
Code List
If No, please tick all items that apply: Side
CL Item
Upper left (1)
CL Item
Lower left (2)
CL Item
Upper right (3)
CL Item
Lower right (4)
Item
Site
text
Site
Code List
Site
CL Item
Deltoid (1)
CL Item
Thigh (2)
CL Item
Buttock (3)
Item
Route
text
Route
Code List
Route
CL Item
I.M. (1)
CL Item
S.C. (2)
Comment
Item
Comment
text
Item Group
Non-administration
Item
Please tick ONE most appropriate category for non administration
text
Please tick ONE most appropriate category for non administration
Code List
Please tick ONE most appropriate category for non administration
CL Item
Serious Adverse Event (complete the SAE form)  (1)
CL Item
Non-Serious adverse event (complete the Non-SAE form) (2)
CL Item
Other (3)
If SAE, specify SAE Number
Item
If SAE, specify SAE Number
integer
If Non-SAE, please specify unsolicited AE Number
Item
If Non-SAE, please specify unsolicited AE Number
integer
If Other, please specify
Item
If Other, please specify
text
Item
Please tick who took the decision
text
Please tick who took the decision
Code List
Please tick who took the decision
CL Item
Investigator (I)
CL Item
Parents/Guardians (P)
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