Serious Adverse Event Record Form

Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
Subject Screening number
Description

Subject Screening No.

Type de données

integer

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

Subject Number

Type de données

integer

Alias
UMLS CUI [1]
C2348585
Serious Adverse Events
Description

Serious Adverse Events

Alias
UMLS CUI-1
C1519255
Did the Subject experience any Serious adverse events?
Description

Serious Adverse Event

Type de données

boolean

Alias
UMLS CUI [1]
C1519255
Staff initials
Description

Staff initials

Type de données

text

Alias
UMLS CUI [1,1]
C2986440
UMLS CUI [1,2]
C1552089
Serious Adverse Event Record
Description

Serious Adverse Event Record

Alias
UMLS CUI-1
C0877248
Serious Adverse Event
Description

Diagnosis only (if known) otherwise signs/symptoms

Type de données

text

Alias
UMLS CUI [1]
C1519255
Start Date
Description

Start Date

Type de données

date

Alias
UMLS CUI [1,1]
C0808070
UMLS CUI [1,2]
C1519255
Start Time
Description

Start Time

Type de données

time

Alias
UMLS CUI [1,1]
C1301880
UMLS CUI [1,2]
C1519255
Outcome
Description

Outcome

Type de données

text

Alias
UMLS CUI [1,1]
C1705586
UMLS CUI [1,2]
C1519255
End Date
Description

End Date

Type de données

date

Alias
UMLS CUI [1,1]
C0806020
UMLS CUI [1,2]
C1519255
End Time
Description

End Time

Type de données

time

Alias
UMLS CUI [1,1]
C1522314
UMLS CUI [1,2]
C1519255
Frequency
Description

Frequency

Type de données

integer

Alias
UMLS CUI [1,1]
C0439603
UMLS CUI [1,2]
C1519255
Maximum Intensity
Description

Maximum Intensity

Type de données

integer

Alias
UMLS CUI [1,1]
C1710056
UMLS CUI [1,2]
C1519255
Action Taken with Investigational Product
Description

Action Taken with Investigational Product

Type de données

integer

Alias
UMLS CUI [1,1]
C1704758
UMLS CUI [1,2]
C1519255
Did the subject withdraw from the study as a result of this AE?
Description

Withdrawal

Type de données

text

Alias
UMLS CUI [1,1]
C1710677
UMLS CUI [1,2]
C1519255
Is there a reasonable possibility that the AE may have been caused by the investigational product
Description

Relationship to Investigational Product

Type de données

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1519255

Similar models

Serious Adverse Event Record Form

Name
Type
Description | Question | Decode (Coded Value)
Type de données
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
Serious Adverse Events
C1519255 (UMLS CUI-1)
Serious Adverse Event
Item
Did the Subject experience any Serious adverse events?
boolean
C1519255 (UMLS CUI [1])
Staff initials
Item
Staff initials
text
C2986440 (UMLS CUI [1,1])
C1552089 (UMLS CUI [1,2])
Item Group
Serious Adverse Event Record
C0877248 (UMLS CUI-1)
Serious Adverse Event
Item
Serious Adverse Event
text
C1519255 (UMLS CUI [1])
Start Date
Item
Start Date
date
C0808070 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Start Time
Item
Start Time
time
C1301880 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item
Outcome
text
C1705586 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
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])
C1519255 (UMLS CUI [1,2])
End Time
Item
End Time
time
C1522314 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item
Frequency
integer
C0439603 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Code List
Frequency
CL Item
Single episode (1)
CL Item
Intermittent (2)
Item
Maximum Intensity
integer
C1710056 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
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])
C1519255 (UMLS CUI [1,2])
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])
C1519255 (UMLS CUI [1,2])
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])
C1519255 (UMLS CUI [1,3])
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)