Inglés

Concomitant Vaccination Form

1 formularios  
Administrative data
Descripción

Administrative data

Subject Number
Descripción

Subject Number

Tipo de datos

integer

Concomitant Vaccination
Descripción

Concomitant Vaccination

Has any vaccine other than the study vaccine(s) been administered during the timeframe as specified in the protocol?
Descripción

Has any vaccine other than the study vaccine(s) been administered during the timeframe as specified in the protocol?

Tipo de datos

boolean

If Yes, please record concomitant vaccination with trade name and /or generic name, route and vaccine administration date
Descripción

If Yes, please record concomitant vaccination with trade name and /or generic name, route and vaccine administration date

Tipo de datos

text

Trade Name / Generic Name
Descripción

Trade Name / Generic Name

Trade / Generic Name
Descripción

Trade / Generic Name

Tipo de datos

text

Route
Descripción

Route

Tipo de datos

text

Administration Date
Descripción

Administration Date

Tipo de datos

date

Volver a la parte superior de la página

Similar models

Concomitant Vaccination Form

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
Item Group
Concomitant Vaccination
Has any vaccine other than the study vaccine(s) been administered during the timeframe as specified in the protocol?
Item
Has any vaccine other than the study vaccine(s) been administered during the timeframe as specified in the protocol?
boolean
If Yes, please record concomitant vaccination with trade name and /or generic name, route and vaccine administration date
Item
If Yes, please record concomitant vaccination with trade name and /or generic name, route and vaccine administration date
text
Item Group
Trade Name / Generic Name
Trade / Generic Name
Item
Trade / Generic Name
text
Item
Route
text
Route
Code List
Route
CL Item
Intradermal (ID) (1)
CL Item
Inhalation (IH) (2)
CL Item
Intramuscular (IM) (3)
CL Item
Intravenous (IV) (4)
CL Item
Intranasal (NA) (5)
CL Item
Other (OTH) (6)
CL Item
Parenteral (PE) (7)
CL Item
Oral (PO) (8)
CL Item
Subcutaneous (SC) (9)
CL Item
Sublingual (SL) (10)
CL Item
Transdermal (TD) (11)
CL Item
Unknown (UNK) (12)
Administration Date
Item
Administration Date
date
Volver a la parte superior de la página