Englisch

Concomitant Vaccination Form

1 Formulare  
Administrative data
Beschreibung

Administrative data

Subject Number
Beschreibung

Subject Number

Datentyp

text

Protocol Number
Beschreibung

Protocol Number

Datentyp

integer

Concomitant Vaccination
Beschreibung

Concomitant Vaccination

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

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

Datentyp

boolean

If Yes, please record the concomitant vaccination details below
Beschreibung

If Yes, please record the concomitant vaccination details below

Datentyp

text

Vaccination details
Beschreibung

Vaccination details

Trade/Generic Name
Beschreibung

Trade/Generic Name

Datentyp

text

Route
Beschreibung

Route

Datentyp

text

Administration Date
Beschreibung

Administration Date

Datentyp

date

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Ähnliche Modelle

Concomitant Vaccination Form

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
text
Protocol Number
Item
Protocol 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 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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