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Visit 4: Concomitant Vaccinations

1 forms  
Administrative data
Description

Administrative data

Subject Number
Description

Subject Number

Data type

integer

Protocol Number
Description

Protocol Number

Data type

integer

Concomitant Vaccination
Description

Concomitant Vaccination

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

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

Data type

boolean

If Yes, please record concomitant vaccination details below
Description

If Yes, please record concomitant vaccination details below

Data type

text

If Yes, please record concomitant vaccination details below
Description

If Yes, please record concomitant vaccination details below

Trade Name/Generic Name
Description

Trade Name/Generic Name

Data type

text

Route
Description

Route

Data type

text

Administration Date
Description

Administration Date

Data type

date

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Similar models

Visit 4: Concomitant Vaccinations

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
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 concomitant vaccination details below
Item
If Yes, please record concomitant vaccination details below
text
Item Group
If Yes, please record concomitant vaccination details below
Trade Name/Generic Name
Item
Trade Name/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
Parenteral (6)
CL Item
Oral (7)
CL Item
Subcutaneous (8)
CL Item
Sublingual (9)
CL Item
Transdermal (10)
CL Item
Unknown (11)
CL Item
Other (12)
Administration Date
Item
Administration Date
date
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