Inglés

Visit 3: Vaccine Administration

1 formularios  
Administrative data
Descripción

Administrative data

Subject Number
Descripción

Subject Number

Tipo de datos

integer

Protocol number
Descripción

Protocol number

Tipo de datos

integer

Date of Visit
Descripción

Date of Visit

Tipo de datos

date

Vaccine Administration
Descripción

Vaccine Administration

Date
Descripción

Date

Tipo de datos

date

Pre-Vaccination temperature
Descripción

Pre-Vaccination temperature

Tipo de datos

float

Unidades de medida
  • °C
°C
Route
Descripción

Route

Tipo de datos

text

Vaccine Administration
Descripción

Vaccine Administration

tick only one box:
Descripción

tick only one box:

Tipo de datos

text

Replacement vial number
Descripción

if applies

Tipo de datos

integer

Wrong vial number
Descripción

If applies

Tipo de datos

integer

Administration side/site/route
Descripción

Administration side/site/route

Side and site
Descripción

Side and site

Tipo de datos

text

Route
Descripción

Route

Tipo de datos

text

Administration according to protocol
Descripción

Administration according to protocol

Has the study vaccine been administered according to the Protocol?
Descripción

Has the study vaccine been administered according to the Protocol?

Tipo de datos

text

Side
Descripción

Side

Tipo de datos

text

Site
Descripción

Site

Tipo de datos

text

Route
Descripción

Route

Tipo de datos

text

Non-administration
Descripción

Non-administration

Why was vaccine not administered?
Descripción

please tick ONE most appropriate category for non admonistration

Tipo de datos

text

If Other, please specify
Descripción

e.g., consent withdrawal, protocol violation

Tipo de datos

text

If SAE, please specify SAE number
Descripción

If SAE, please specify SAE number

Tipo de datos

integer

If Non-SAE, please specify unsolicited AE number
Descripción

If Non-SAE, please specify unsolicited AE number

Tipo de datos

integer

Please tick who took the decision
Descripción

Please tick who took the decision

Tipo de datos

text

Immediate Post-Vaccination Observation
Descripción

Immediate Post-Vaccination Observation

If any AE occurred during the immediate post-vaccination time (30 min), please fill in the Solicited Adverse Events section, the Non-SAE section or a SAE section.
Descripción

If any AE occurred during the immediate post-vaccination time (30 min), please fill in the Solicited Adverse Events section, the Non-SAE section or a SAE section.

Tipo de datos

text

If any prophylactic medication has been administered in anticipation of study vaccine reaction, please complete the Medication section and tick "Prophylactic" box.
Descripción

If any prophylactic medication has been administered in anticipation of study vaccine reaction, please complete the Medication section and tick "Prophylactic" box.

Tipo de datos

text

Any other vaccines administered during the study period must be recorded in the Concomitant Vaccination section.
Descripción

Any other vaccines administered during the study period must be recorded in the Concomitant Vaccination section.

Tipo de datos

text

Volver a la parte superior de la página

Similar models

Visit 3: Vaccine Administration

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
Protocol number
Item
Protocol number
integer
Date of Visit
Item
Date of Visit
date
Item Group
Vaccine Administration
Date
Item
Date
date
Pre-Vaccination temperature
Item
Pre-Vaccination temperature
float
Item
Route
text
Route
Code List
Route
CL Item
Axillary (1)
CL Item
Oral (2)
CL Item
Tympanic (oral conversion) (3)
CL Item
Tympanic (rectal conversion) (4)
CL Item
Rectal (5)
Item Group
Vaccine Administration
Item
tick only one box:
text
tick only one box:
Code List
tick only one box:
CL Item
DTPw-HBV/Hib Kft Vaccine (1)
CL Item
Replacement vial (2)
CL Item
Wrong vial number (3)
CL Item
Not administered (4)
Replacement vial number
Item
Replacement vial number
integer
Wrong vial number
Item
Wrong vial number
integer
Item Group
Administration side/site/route
Item
Side and site
text
Side and site
Code List
Side and site
CL Item
Upper right thigh (1)
Item
Route
text
Route
Code List
Route
CL Item
IM (1)
Item Group
Administration according to protocol
Item
Has the study vaccine been administered according to the Protocol?
text
Has the study vaccine been administered according to the Protocol?
Code List
Has the study vaccine been administered according to the Protocol?
CL Item
Yes (1)
CL Item
No -> please tick all below items that apply (2)
Item
Side
text
Side
Code List
Side
CL Item
Upper left (1)
CL Item
Lower left (2)
CL Item
Upper right (3)
CL Item
Lower right (4)
Item
Site
text
Site
Code List
Site
CL Item
Deltoid (1)
CL Item
Thigh (2)
CL Item
Buttock (3)
Item
Route
text
Route
Code List
Route
CL Item
I.M. (1)
CL Item
S.C. (2)
Item Group
Non-administration
Item
Why was vaccine not administered?
text
Why was vaccine not administered?
Code List
Why was vaccine not administered?
CL Item
Serious Adverse Event (1)
CL Item
Non-Serious Adverse Event  (2)
CL Item
Other (3)
If Other, please specify
Item
If Other, please specify
text
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
Item
Please tick who took the decision
text
Please tick who took the decision
Code List
Please tick who took the decision
CL Item
Investigator (1)
CL Item
Parents/Guardians (2)
Item Group
Immediate Post-Vaccination Observation
If any AE occurred during the immediate post-vaccination time (30 min), please fill in the Solicited Adverse Events section, the Non-SAE section or a SAE section.
Item
If any AE occurred during the immediate post-vaccination time (30 min), please fill in the Solicited Adverse Events section, the Non-SAE section or a SAE section.
text
If any prophylactic medication has been administered in anticipation of study vaccine reaction, please complete the Medication section and tick "Prophylactic" box.
Item
If any prophylactic medication has been administered in anticipation of study vaccine reaction, please complete the Medication section and tick "Prophylactic" box.
text
Any other vaccines administered during the study period must be recorded in the Concomitant Vaccination section.
Item
Any other vaccines administered during the study period must be recorded in the Concomitant Vaccination section.
text
Volver a la parte superior de la página