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Visit 4: Non-Serious Adverse Events Form

1 Formulários  
Administrative data
Descrição

Administrative data

Subject Number
Descrição

Subject Number

Tipo de dados

integer

Protocol Number
Descrição

Protocol Number

Tipo de dados

integer

Non-Serious Adverse Events
Descrição

Non-Serious Adverse Events

Has any non-serious adverse event occurred within one month post-vaccination, excluding those recorded on the Solicited AE forms?
Descrição

Please report all SAE only on the SAE-form.

Tipo de dados

boolean

If Yes, please complete the section below
Descrição

If Yes, please complete the section below

Tipo de dados

text

Non-Serious Adverse Events Data
Descrição

Non-Serious Adverse Events Data

AE Number
Descrição

AE Number

Tipo de dados

integer

Description
Descrição

Description

Tipo de dados

text

Administration sites
Descrição

Administration sites

Tipo de dados

text

Date Started
Descrição

Date Started

Tipo de dados

date

Date Stopped
Descrição

Date Stopped

Tipo de dados

date

Intensity
Descrição

Intensity

Tipo de dados

text

Is there a reasonable possibility that the AE may have been caused by the investigational product?
Descrição

Is there a reasonable possibility that the AE may have been caused by the investigational product?

Tipo de dados

boolean

Outcome
Descrição

Outcome

Tipo de dados

text

Medically attended visit
Descrição

Medically attended visit

Tipo de dados

boolean

If Yes, record the type of visit
Descrição

If Yes, record the type of visit

Tipo de dados

text

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Similar models

Visit 4: Non-Serious Adverse Events Form

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
Protocol Number
Item
Protocol Number
integer
Item Group
Non-Serious Adverse Events
Has any non-serious adverse event occurred within one month post-vaccination, excluding those recorded on the Solicited AE forms?
Item
Has any non-serious adverse event occurred within one month post-vaccination, excluding those recorded on the Solicited AE forms?
boolean
If Yes, please complete the section below
Item
If Yes, please complete the section below
text
Item Group
Non-Serious Adverse Events Data
Item
AE Number
integer
AE Number
Code List
AE Number
CL Item
Event 1 (1)
CL Item
Event 2 (2)
CL Item
Event 3 (3)
CL Item
Event 4 (4)
Description
Item
Description
text
Item
Administration sites
text
Administration sites
Code List
Administration sites
CL Item
DTPw-HBV/Hib Kft vaccine (1)
CL Item
DTPw-HBV Kft vaccine (2)
CL Item
HiberixTM vaccine (3)
CL Item
Non-administration site (4)
Date Started
Item
Date Started
date
Date Stopped
Item
Date Stopped
date
Item
Intensity
text
Intensity
Code List
Intensity
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Is there a reasonable possibility that the AE may have been caused by the investigational product?
Item
Is there a reasonable possibility that the AE may have been caused by the investigational product?
boolean
Item
Outcome
text
Outcome
Code List
Outcome
CL Item
Recovered/Resolved (1)
CL Item
Recovering/Resolving (2)
CL Item
Not recovered/Not resolved (3)
CL Item
Recovered with sequelae/resolved with sequelae (4)
Medically attended visit
Item
Medically attended visit
boolean
Item
If Yes, record the type of visit
text
If Yes, record the type of visit
Code List
If Yes, record the type of visit
CL Item
Hospitalisation (1)
CL Item
Emergency Room (2)
CL Item
Medical Personnel (3)
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