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Non-Serious Adverse Events Form

1 forms  
Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
Subject Screening number
Description

Subject Screening No.

Data type

integer

Alias
UMLS CUI [1,1]
C0220908
UMLS CUI [1,2]
C0600091
Subject no.
Description

Subject Number

Data type

integer

Alias
UMLS CUI [1]
C2348585
Non-serious Adverse Events
Description

Non-serious Adverse Events

Alias
UMLS CUI-1
C1518404
Did the subject experience any NSAE?
Description

Non Serious Adverse Event

Data type

boolean

Alias
UMLS CUI [1]
C1518404
Staff initials
Description

Staff initials

Data type

text

Alias
UMLS CUI [1,1]
C2986440
UMLS CUI [1,2]
C1552089
Non-serious Adverse Events Record
Description

Non-serious Adverse Events Record

Alias
UMLS CUI-1
C1518404
Non-serious Adverse Event
Description

Diagnosis only (if known) otherwise signs/symptoms

Data type

text

Alias
UMLS CUI [1]
C1518404
Start Date
Description

Start Date

Data type

date

Alias
UMLS CUI [1,1]
C0808070
UMLS CUI [1,2]
C1518404
Start Time
Description

Start Time

Data type

time

Alias
UMLS CUI [1,1]
C1301880
UMLS CUI [1,2]
C1518404
Outcome
Description

Outcome

Data type

text

Alias
UMLS CUI [1,1]
C1705586
UMLS CUI [1,2]
C1518404
End Date
Description

End Date

Data type

date

Alias
UMLS CUI [1,1]
C0806020
UMLS CUI [1,2]
C1518404
End Time
Description

End Time

Data type

time

Alias
UMLS CUI [1,1]
C1522314
UMLS CUI [1,2]
C1518404
Frequency
Description

Frequency

Data type

integer

Alias
UMLS CUI [1,1]
C0439603
UMLS CUI [1,2]
C1518404
Maximum Intensity
Description

Maximum Intensity

Data type

integer

Alias
UMLS CUI [1,1]
C1710056
UMLS CUI [1,2]
C1518404
Action Taken with Investigational Product
Description

Action Taken with Investigational Product

Data type

integer

Alias
UMLS CUI [1,1]
C1704758
UMLS CUI [1,2]
C1518404
Did the subject withdraw from the study as a result of this AE?
Description

Withdrawal

Data type

text

Alias
UMLS CUI [1,1]
C1710677
UMLS CUI [1,2]
C1518404
Is there a reasonable possibility that the AE may have been caused by the investigational product
Description

Relationship to Investigational Product

Data type

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1518404
Conclusion
Description

Conclusion

Alias
UMLS CUI-1
C1707478
Is this the last page of Non-serious Adverse Events?
Description

Last Page

Data type

boolean

Alias
UMLS CUI [1,1]
C1704732
UMLS CUI [1,2]
C1517741
UMLS CUI [1,3]
C1518404
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Similar models

Non-Serious Adverse Events Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Subject Screening No.
Item
Subject Screening number
integer
C0220908 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Subject Number
Item
Subject no.
integer
C2348585 (UMLS CUI [1])
Item Group
Non-serious Adverse Events
C1518404 (UMLS CUI-1)
Non Serious Adverse Event
Item
Did the subject experience any NSAE?
boolean
C1518404 (UMLS CUI [1])
Staff initials
Item
Staff initials
text
C2986440 (UMLS CUI [1,1])
C1552089 (UMLS CUI [1,2])
Item Group
Non-serious Adverse Events Record
C1518404 (UMLS CUI-1)
Non-serious Adverse Event
Item
Non-serious Adverse Event
text
C1518404 (UMLS CUI [1])
Start Date
Item
Start Date
date
C0808070 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Start Time
Item
Start Time
time
C1301880 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Item
Outcome
text
C1705586 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Outcome
Code List
Outcome
CL Item
Recovered/Resolved (1)
CL Item
Recovering/Resolving (2)
CL Item
Not recovered/ Not resolving (3)
CL Item
Recovered/Resolved with sequelae (4)
End Date
Item
End Date
date
C0806020 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
End Time
Item
End Time
time
C1522314 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Item
Frequency
integer
C0439603 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Frequency
Code List
Frequency
CL Item
Single episode (1)
CL Item
Intermittent (2)
Item
Maximum Intensity
integer
C1710056 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Maximum Intensity
Code List
Maximum Intensity
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
CL Item
Not applicable (4)
Item
Action Taken with Investigational Product
integer
C1704758 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Action Taken with Investigational Product
Code List
Action Taken with Investigational Product
CL Item
Withdrawn (1)
CL Item
Dose reduced (2)
CL Item
Dose increased (3)
CL Item
Dose not changed (4)
CL Item
Dose interrupted (5)
CL Item
Not Applicable (6)
Item
Did the subject withdraw from the study as a result of this AE?
text
C1710677 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Withdrawal
Code List
Did the subject withdraw from the study as a result of this AE?
CL Item
Yes (Y)
CL Item
No (N)
Item
Is there a reasonable possibility that the AE may have been caused by the investigational product
text
C0304229 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
Relationship to Investigational Product
Code List
Is there a reasonable possibility that the AE may have been caused by the investigational product
CL Item
Yes (Y)
CL Item
No (N)
Item Group
Conclusion
C1707478 (UMLS CUI-1)
Last Page
Item
Is this the last page of Non-serious Adverse Events?
boolean
C1704732 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
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