ID

33494

Beschreibung

Study ID: 104065 Clinical Study ID: 104065 Study Title: Immune memory of GSK's DTPw-HBV/Hib vaccine by giving Plain PRP polysaccharide at 10 mths. Immuno & reacto of a booster dose of DTPw-HBV/Hib or DTPw-HBV or DTPw-HBV+Hib at 15-18 mths in infants previously primed with DTPw-HBV/Hib Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00169442  Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 3 Study Recruitment Status: Completet Generic Name: Combined Diphtheria, Tetanus, Whole Cell Pertussis, Hepatitis B, Haemophilus influenzae Type b Vaccine (KFT) Trade Name: Zilbrix/Hib Study Indication: Diphtheria; Haemophilus influenzae type b; Hepatitis B; Tetanus; Whole Cell Pertussis

Stichworte

Versionen (1)
  1. 11.12.18 11.12.18 -
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GSK group of companies

Hochgeladen am

11. Dezember 2018

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Immune memory of Combined Diphtheria, Tetanus, Whole Cell Pertussis, Hepatitis B, Haemophilus influenzae Type b Vaccine at infants (15 to 18 mths) - 104065

Englisch

Diary card: General Symptoms (DTPw-HBV Kft+HiberixTM)

1 Formulare  
Administrative data
Beschreibung

Administrative data

Subject Number
Beschreibung

Subject Number

Datentyp

integer

Protocol Number
Beschreibung

Protocol Number

Datentyp

integer

General Symptoms
Beschreibung

General Symptoms

Please fill in below and assess the occurrence of any of the following signs or symptoms according to the criteria listed below.
Beschreibung

assess the occurrence of general signs or symptoms

Datentyp

text

Temperature
Beschreibung

Temperature

Day
Beschreibung

Day

Datentyp

text

Route
Beschreibung

Route

Datentyp

integer

Temperature
Beschreibung

Temperature

Datentyp

float

Maßeinheiten
  • °C
°C
Ongoing after day 3?
Beschreibung

Ongoing after day 3?

Datentyp

boolean

If Yes, record the date of last day of symptoms
Beschreibung

If Yes, record the date of last day of symptoms

Datentyp

date

Was the visit medically attended?
Beschreibung

Medically attended Visit?

Datentyp

boolean

Irritability/Fussiness
Beschreibung

Irritability/Fussiness

Day
Beschreibung

Day

Datentyp

integer

Intensity
Beschreibung

Intensity

Datentyp

text

Ongoing after day 3?
Beschreibung

Ongoing after day 3?

Datentyp

boolean

If Yes, record the date of last day of symptoms
Beschreibung

If Yes, record the date of last day of symptoms

Datentyp

date

Was the visit medically attended?
Beschreibung

medically attended visit?

Datentyp

boolean

Was the crying continuous?
Beschreibung

In case of crying that connot be comforted and prevents normal activity; i.e. not episodic, not interrupted within the time period of 3 hours by e.g. naps?

Datentyp

boolean

Was the crying unaltered >=3 hours?
Beschreibung

unaltered crying >= 3 hrs

Datentyp

boolean

Drowsiness
Beschreibung

Drowsiness

Day
Beschreibung

Day

Datentyp

integer

Intensity
Beschreibung

Intensity

Datentyp

text

Ongoing after day 3?
Beschreibung

Ongoing after day 3?

Datentyp

boolean

If Yes, record the date of last day of symptoms
Beschreibung

If Yes, record the date of last day of symptoms

Datentyp

date

medically attended visit?
Beschreibung

medically attended visit?

Datentyp

boolean

Loss of Appetite
Beschreibung

Loss of Appetite

Day
Beschreibung

Day

Datentyp

integer

Intensity
Beschreibung

Intensity

Datentyp

text

Ongoing after day 3?
Beschreibung

Ongoing after day 3?

Datentyp

boolean

If Yes, record the date of last day of symptoms
Beschreibung

If Yes, record the date of last day of symptoms

Datentyp

date

medically attended visit?
Beschreibung

medically attended visit?

Datentyp

boolean

Other General Symptoms
Beschreibung

Other General Symptoms

Description
Beschreibung

please give details below

Datentyp

integer

Intensity
Beschreibung

Intensity

Datentyp

text

Start date
Beschreibung

Start date

Datentyp

date

End date
Beschreibung

End date

Datentyp

date

Ongoing?
Beschreibung

Ongoing?

Datentyp

boolean

Was the visit medically attended?
Beschreibung

medically attended visit?

Datentyp

boolean

Medications
Beschreibung

Medications

Trade name/Generic name
Beschreibung

Trade name/Generic name

Datentyp

text

Reason
Beschreibung

Reason

Datentyp

text

Total daily dose
Beschreibung

Total daily dose

Datentyp

text

Start date
Beschreibung

Start date

Datentyp

date

End date
Beschreibung

End date

Datentyp

date

Ongoing?
Beschreibung

Ongoing?

Datentyp

boolean

Reminder
Beschreibung

Reminder

Please do not forget to bring back the diary card on
Beschreibung

Record the date below

Datentyp

date

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Ähnliche Modelle

Diary card: General Symptoms (DTPw-HBV Kft+HiberixTM)

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
Protocol Number
Item
Protocol Number
integer
Item Group
General Symptoms
assess the occurrence of general signs or symptoms
Item
Please fill in below and assess the occurrence of any of the following signs or symptoms according to the criteria listed below.
text
Item Group
Temperature
Item
Day
text
Day
Code List
Day
CL Item
Day 0 (1)
CL Item
Day 1 (2)
CL Item
Day 2 (3)
CL Item
Day 3 (4)
Item
Route
integer
Route
Code List
Route
CL Item
Axillary (1)
CL Item
Oral (2)
CL Item
Tympanic oral (3)
CL Item
Tympanic rectal (4)
CL Item
Rectal (5)
Temperature
Item
Temperature
float
Ongoing after day 3?
Item
Ongoing after day 3?
boolean
If Yes, record the date of last day of symptoms
Item
If Yes, record the date of last day of symptoms
date
Medically attended Visit?
Item
Was the visit medically attended?
boolean
Item Group
Irritability/Fussiness
Item
Day
integer
Day
Code List
Day
CL Item
Day 0 (1)
CL Item
Day 1 evening (2)
CL Item
Day 2 evening (3)
CL Item
Day 3 evening (4)
Item
Intensity
text
Intensity
Code List
Intensity
CL Item
Behaviour as usual (1)
CL Item
Crying more than usual/ no effect on normal activity (2)
CL Item
Crying more than usual/ interferes with normal activity (3)
CL Item
Crying that cannot be comforted/ prevents normal activity (4)
Ongoing after day 3?
Item
Ongoing after day 3?
boolean
If Yes, record the date of last day of symptoms
Item
If Yes, record the date of last day of symptoms
date
medically attended visit?
Item
Was the visit medically attended?
boolean
Continuous crying?
Item
Was the crying continuous?
boolean
unaltered crying >= 3 hrs
Item
Was the crying unaltered >=3 hours?
boolean
Item Group
Drowsiness
Item
Day
integer
Day
Code List
Day
CL Item
Day 0 (1)
CL Item
Day 1 evening (2)
CL Item
Day 2 evening (3)
CL Item
Day 3 evening (4)
Item
Intensity
text
Intensity
Code List
Intensity
CL Item
Behavior as usual (1)
CL Item
Drowsiness easily tolerated (2)
CL Item
Drowsiness that interferes with normal activity (3)
CL Item
Drowsiness that prevents normal activity (4)
Ongoing after day 3?
Item
Ongoing after day 3?
boolean
If Yes, record the date of last day of symptoms
Item
If Yes, record the date of last day of symptoms
date
medically attended visit?
Item
medically attended visit?
boolean
Item Group
Loss of Appetite
Item
Day
integer
Day
Code List
Day
CL Item
Day 0 (1)
CL Item
Day 1 evening (2)
CL Item
Day 2 evening (3)
CL Item
Day 3 evening (4)
Item
Intensity
text
Intensity
Code List
Intensity
CL Item
Appetite as usual (1)
CL Item
Eating less than usual / no effect on normal activity (2)
CL Item
Eating less than usual / interferes with normal activity (3)
CL Item
Not eating at all (4)
Ongoing after day 3?
Item
Ongoing after day 3?
boolean
If Yes, record the date of last day of symptoms
Item
If Yes, record the date of last day of symptoms
date
medically attended visit?
Item
medically attended visit?
boolean
Item Group
Other General Symptoms
Description
Item
Description
integer
Item
Intensity
text
Intensity
Code List
Intensity
CL Item
Mild (an AE which is easily tolerated by the subject, causing minimal discomfort and non interfering with everyday activities) (1)
CL Item
Moderate (an AE which is sufficiently discomforting to interfere with normal everyday activities) (2)
CL Item
Severe (an AE which prevents normal, everyday activities: attendance at school/kindergarten/a day-care center and would cause the parents/guardians to seek medical advice) (3)
Start date
Item
Start date
date
End date
Item
End date
date
Ongoing?
Item
Ongoing?
boolean
medically attended visit?
Item
Was the visit medically attended?
boolean
Item Group
Medications
Trade name/Generic name
Item
Trade name/Generic name
text
Reason
Item
Reason
text
Total daily dose
Item
Total daily dose
text
Start date
Item
Start date
date
End date
Item
End date
date
Ongoing?
Item
Ongoing?
boolean
Item Group
Reminder
Please do not forget to bring back the diary card on
Item
Please do not forget to bring back the diary card on
date
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