Engelsk

Concomitant Vaccination Form

1 Formulär  
Administrative data
Beskrivning

Administrative data

Subject Number
Beskrivning

Subject Number

Datatyp

text

Concomitant Vaccination
Beskrivning

Concomitant Vaccination

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

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

Datatyp

boolean

If Yes, please record the concomitant vaccination details below
Beskrivning

If Yes, please record the concomitant vaccination details below

Datatyp

text

Vaccination details
Beskrivning

Vaccination details

Trade/Generic Name
Beskrivning

Trade/Generic Name

Datatyp

text

Route
Beskrivning

Route

Datatyp

text

Administration Date
Beskrivning

Administration Date

Datatyp

date

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Similar models

Concomitant Vaccination Form

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
text
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 the concomitant vaccination details below
Item
If Yes, please record the concomitant vaccination details below
text
Item Group
Vaccination details
Trade/Generic Name
Item
Trade/Generic Name
text
Item
Route
text
Route
Code List
Route
CL Item
Intradermal (1)
CL Item
Inhalation (2)
CL Item
Intramuscular (3)
CL Item
Intravenous (4)
CL Item
Intranasal (5)
CL Item
Other (6)
CL Item
Parenteral (7)
CL Item
Oral (8)
CL Item
Subcutaneous (9)
CL Item
Sublingual (10)
CL Item
Transdermal (11)
CL Item
Unknown (12)
Administration Date
Item
Administration Date
date
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