Anglais

Reason for Non Participation - Tracking Form

1 Formulaires  
Administrative data
Description

Administrative data

Protocol Number
Description

Protocol Number

Type de données

text

Previous study
Description

Previous study

Type de données

text

Center Number
Description

Center number

Type de données

integer

Reason for non participation
Description

Reason for non participation

Subject Number
Description

Subject Number

Type de données

integer

Subject could not be reached due to
Description

Subject could not be reached due to

Type de données

text

Subject could be contacted
Description

Subject could be contacted

Type de données

text

Record eligibility criteria that was failed
Description

if applies

Type de données

text

Subject is eligible but not willing to participate due to
Description

if applies

Type de données

text

Day of contact
Description

Day of contact

Type de données

date

In case of death, date of contact not requested
Description

In case of death, date of contact not requested

Investigator's Signature
Description

Investigator's Signature

Investigator's name (in Print)
Description

Investigator's name (in Print)

Type de données

text

Investigator's Signature
Description

Investigator's Signature

Type de données

text

Date
Description

Date

Type de données

date

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Similar models

Reason for Non Participation - Tracking Form

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Administrative data
Protocol Number
Item
Protocol Number
text
Item
Previous study
text
Previous study
Code List
Previous study
CL Item
257049/026 (Malaria-026) (1)
Center number
Item
Center Number
integer
Item Group
Reason for non participation
Subject Number
Item
Subject Number
integer
Item
Subject could not be reached due to
text
Subject could not be reached due to
Code List
Subject could not be reached due to
CL Item
Lost to follow-up (1)
CL Item
Migrated/moved from study area (2)
CL Item
Death (3)
Item
Subject could be contacted
text
Subject could be contacted
Code List
Subject could be contacted
CL Item
Not eligible (record criteria) (1)
CL Item
Eligible but not willing to participate (record reason for it) (2)
Record eligibility criteria that was failed
Item
Record eligibility criteria that was failed
text
Item
Subject is eligible but not willing to participate due to
text
Subject is eligible but not willing to participate due to
Code List
Subject is eligible but not willing to participate due to
CL Item
Consent withdrawal not due to an AE (1)
CL Item
Serious adverse event (2)
CL Item
Adverse event (3)
CL Item
Other (4)
Day of contact
Item
Day of contact
date
Item Group
In case of death, date of contact not requested
Item Group
Investigator's Signature
Investigator's name (in Print)
Item
Investigator's name (in Print)
text
Investigator's Signature
Item
Investigator's Signature
text
Date
Item
Date
date
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