Did the subject experience any Serious Adverse Events during the study period?
Item
Did the subject experience any Serious Adverse Events during the study period?
boolean
If Yes, please specify total number of SAE's
Item
If Yes, please specify total number of SAE's
integer
Was the treatment blind broken during this study?
Item
Was the treatment blind broken during this study?
boolean
If Yes, please complete date
Item
If Yes, please complete date
date
Item
Check the reason of blind breach
integer
Code List
Check the reason of blind breach
CL Item
Medical emergency requiring identification of investigational product for further treatments (1)
If Other, specify
Item
If Other, specify
text
Did any elimination criteria become applicable during the study?
Item
Did any elimination criteria become applicable during the study?
boolean
If Yes, specify
Item
If Yes, specify
text
Was the subject withdrawn from study?
Item
Was the subject withdrawn from study?
boolean
Item
If Yes, please tick the ONE most appropriate category for withdrawal
text
Code List
If Yes, please tick the ONE most appropriate category for withdrawal
CL Item
Serious adverse event (check SAE number) (1)
CL Item
Non-Serious adverse events (check the Non-SAE) (2)
CL Item
Protocol violation (3)
CL Item
Consent withdrawal, not due to an adverse event (4)
CL Item
Migrated/moved from the study area (5)
CL Item
Lost to follow-up (6)
If SAE, please specify SAE Number
Item
If SAE, please specify SAE Number
integer
If Non-SAE please specify unsolicited AE Number
Item
If Non-SAE please specify unsolicited AE Number
integer
If Protocol violation, please specify
Item
If Protocol violation, please specify
text
If Other, please specify
Item
If Other, please specify
text
Item
Please tick who took decision
text
Code List
Please tick who took decision
CL Item
Parents/Guardians (2)
Date of last contact
Item
Date of last contact
date
Item
Was the subject in good condition at date of last contact?
text
Code List
Was the subject in good condition at date of last contact?
CL Item
No, please give details within the Adverse Events section (2)
I confirm that I have reviewed the data in this Case Report Form for this subject. All information entered by myself or my collegues is, to the best of my knowledge, complete and accurate, as of the date below.
Item
I confirm that I have reviewed the data in this Case Report Form for this subject. All information entered by myself or my collegues is, to the best of my knowledge, complete and accurate, as of the date below.
date
Investigator's signature
Item
Investigator's signature
text
Printed Investigator's name
Item
Printed Investigator's name
text