ID

33378

Beschrijving

Study ID: 107806 Clinical Study ID: RA3107806 Study Title: An open label study to determine the safety, tolerability, excretion balance and pharmacokinetics of Losmapimod, administered as a single dose of an oral solution to healthy adult male subjects Patient Level Data: Clinicaltrials.gov Identifier: NCT00599612 https://clinicaltrials.gov/ct2/show/NCT00599612 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 1 Study Recruitment Status: Completed Generic Name: losmapimod Trade Name: losmapimod Study Indication: Pulmonary Disease, Chronic Obstructive The study consists of a screening, study visit and follow-up. The protocol identifier for all: RA3107806 This document contains the Pharmacogenetic (PGx) research form. It has to be filled in if a PGx was done during study.

Link

https://clinicaltrials.gov/ct2/show/NCT00599612

Trefwoorden

Versies (2)
  1. 04-12-18 04-12-18 -
  2. 07-12-18 07-12-18 -
Houder van rechten

GlaxoSmithKline

Geüploaded op

7 december 2018

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Safety, tolerability, excretion balance and pharmacokinetics of Losmapimod in healthy males, NCT00599612

Engels

Pharmacogenetic (PGx) research

1 Formulieren  
Administrative data
Beschrijving

Administrative data

Alias
UMLS CUI-1
C1320722
Subject identifier
Beschrijving

Subject identifier

Datatype

text

Alias
UMLS CUI [1]
C2348585
Consent for pharmacogenetic (PGx) research (DNA)
Beschrijving

Consent for pharmacogenetic (PGx) research (DNA)

Alias
UMLS CUI-1
C0021430
UMLS CUI-2
C2347500
Has informed consent been obtained for PGx research?
Beschrijving

Informed consent for PGx

Datatype

text

Alias
UMLS CUI [1,1]
C0021430
UMLS CUI [1,2]
C2347500
If you ticked yes in "informed consent for PGx", record the date informed consent obtained for PGx research
Beschrijving

day month year

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0009797
If you ticked no in "informed consent for PGx", please tick one reason
Beschrijving

No informed consent, reason

Datatype

text

Alias
UMLS CUI [1,1]
C0021430
UMLS CUI [1,2]
C1272696
UMLS CUI [1,3]
C0566251
If other reason, please specify
Beschrijving

Other reason for none informed consent

Datatype

text

Alias
UMLS CUI [1,1]
C0021430
UMLS CUI [1,2]
C1272696
UMLS CUI [1,3]
C0205394
UMLS CUI [1,4]
C0566251
Blood sample collection
Beschrijving

Blood sample collection

Alias
UMLS CUI-1
C0005834
Has a blood sample been collected for PGx research?
Beschrijving

Blood sample collection for PGx

Datatype

text

Alias
UMLS CUI [1,1]
C0005834
UMLS CUI [1,2]
C0031325
If you ticked yes in "blood sample collection for PGx" record the date sample taken
Beschrijving

day month year

Datatype

date

Alias
UMLS CUI [1,1]
C0005834
UMLS CUI [1,2]
C0031325
UMLS CUI [1,3]
C0011008
Withdrawl of consent
Beschrijving

Withdrawl of consent

Alias
UMLS CUI-1
C1707492
Has subject withdrawn consent for PGx research?
Beschrijving

Withdrawn consent for PGx

Datatype

text

Alias
UMLS CUI [1,1]
C1707492
UMLS CUI [1,2]
C0031325
If you ticked yes in "withdrawn consent for PGx", record the date informed consent withdrawn for PGx research
Beschrijving

Date of informed consent withdraw

Datatype

date

Alias
UMLS CUI [1,1]
C1707492
UMLS CUI [1,2]
C0031325
UMLS CUI [1,3]
C0011008
Blood sample destruction
Beschrijving

Blood sample destruction

Alias
UMLS CUI-1
C1948029
UMLS CUI-2
C0178913
Has a request been made for blood sample destruction?
Beschrijving

Request for blood sample destruction

Datatype

text

Alias
UMLS CUI [1,1]
C1948029
UMLS CUI [1,2]
C0178913
UMLS CUI [1,3]
C1272683
If request, please tick one reason
Beschrijving

Reason for request

Datatype

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C1272683
If other reason, please specify
Beschrijving

Other reason for request

Datatype

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0566251
UMLS CUI [1,3]
C1272683
Terug naar het begin van de pagina

Similar models

Pharmacogenetic (PGx) research

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Subject identifier
Item
Subject identifier
text
C2348585 (UMLS CUI [1])
Item Group
Consent for pharmacogenetic (PGx) research (DNA)
C0021430 (UMLS CUI-1)
C2347500 (UMLS CUI-2)
Item
Has informed consent been obtained for PGx research?
text
C0021430 (UMLS CUI [1,1])
C2347500 (UMLS CUI [1,2])
Informed consent for PGx
Code List
Has informed consent been obtained for PGx research?
CL Item
Yes (Y)
CL Item
No (N)
Date of informed consent
Item
If you ticked yes in "informed consent for PGx", record the date informed consent obtained for PGx research
date
C0011008 (UMLS CUI [1,1])
C0009797 (UMLS CUI [1,2])
Item
If you ticked no in "informed consent for PGx", please tick one reason
text
C0021430 (UMLS CUI [1,1])
C1272696 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
No informed consent, reason
Code List
If you ticked no in "informed consent for PGx", please tick one reason
CL Item
Subject declined (1)
CL Item
Subject not asked by Investigator (2)
CL Item
Other (Z)
Item
If other reason, please specify
text
C0021430 (UMLS CUI [1,1])
C1272696 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C0566251 (UMLS CUI [1,4])
No informed consent, reason
Code List
If other reason, please specify
Item Group
Blood sample collection
C0005834 (UMLS CUI-1)
Item
Has a blood sample been collected for PGx research?
text
C0005834 (UMLS CUI [1,1])
C0031325 (UMLS CUI [1,2])
Blood sample collection for PGx
Code List
Has a blood sample been collected for PGx research?
CL Item
Yes (Y)
CL Item
No (N)
Date of blood sample collection
Item
If you ticked yes in "blood sample collection for PGx" record the date sample taken
date
C0005834 (UMLS CUI [1,1])
C0031325 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item Group
Withdrawl of consent
C1707492 (UMLS CUI-1)
Item
Has subject withdrawn consent for PGx research?
text
C1707492 (UMLS CUI [1,1])
C0031325 (UMLS CUI [1,2])
Withdrawn consent for PGx
Code List
Has subject withdrawn consent for PGx research?
CL Item
Yes (Y)
CL Item
No (N)
Date of informed consent withdraw
Item
If you ticked yes in "withdrawn consent for PGx", record the date informed consent withdrawn for PGx research
date
C1707492 (UMLS CUI [1,1])
C0031325 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item Group
Blood sample destruction
C1948029 (UMLS CUI-1)
C0178913 (UMLS CUI-2)
Item
Has a request been made for blood sample destruction?
text
C1948029 (UMLS CUI [1,1])
C0178913 (UMLS CUI [1,2])
C1272683 (UMLS CUI [1,3])
Request for blood sample destruction
Code List
Has a request been made for blood sample destruction?
CL Item
Yes (Y)
CL Item
No (N)
Item
If request, please tick one reason
text
C0566251 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
Reason for request
Code List
If request, please tick one reason
CL Item
Subject withdrew consent for PGx (1)
CL Item
Screen failure (2)
CL Item
Other (Z)
Other reason for request
Item
If other reason, please specify
text
C0205394 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
C1272683 (UMLS CUI [1,3])
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial