Inglese

Visit 6: Eligibility Check, Laboratory Test

1 moduli  
Administrative data
Descrizione

Administrative data

Visit Number
Descrizione

Visit Number

Tipo di dati

integer

Day
Descrizione

Day

Tipo di dati

text

Subject Number
Descrizione

Subject Number

Tipo di dati

integer

Date of Visit
Descrizione

Date of Visit

Tipo di dati

date

Check for Study Continuation
Descrizione

Check for Study Continuation

Did the subject return for Visit 6?
Descrizione

Did the subject return for Visit 6?

Tipo di dati

boolean

If No, please tick ONE most appropriate reason
Descrizione

If No, please tick ONE most appropriate reason

Tipo di dati

text

If Other, please specify
Descrizione

If Other, please specify

Tipo di dati

text

If SAE, record the SAE number
Descrizione

If SAE, record the SAE number

Tipo di dati

integer

If non-SAE, please record the AE number
Descrizione

If non-SAE, please record the AE number

Tipo di dati

integer

Please tick who took the decision
Descrizione

Please tick who took the decision

Tipo di dati

text

Elimination Criteria During The Study
Descrizione

Elimination Criteria During The Study

The following criteria should be checked at each visit subsequent to the first visit.
Descrizione

If any of the criteria become applicable during the study, it will not require withdrawal of the subject from the study but may determine a subject's evaluability in the according-to-protocol (ATP) analysis.

Tipo di dati

text

1. Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s) during the study period
Descrizione

1. Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s) during the study period

Tipo di dati

text

2. Chronic administration (defined as more than 14 days) or immunodepressants or other imminodefying drugs during the study period.
Descrizione

2. Chronic administration (defined as more than 14 days) or immunodepressants or other imminodefying drugs during the study period.

Tipo di dati

text

3. Administration of a vaccine not foreseen by the study protocol during the period starting from 30 days before each dose of vaccine(s) and ending 30 days after
Descrizione

3. Administration of a vaccine not foreseen by the study protocol during the period starting from 30 days before each dose of vaccine(s) and ending 30 days after

Tipo di dati

text

4. Administration of immunoglobulins and/or any blood products during the study period
Descrizione

4. Administration of immunoglobulins and/or any blood products during the study period

Tipo di dati

text

Laboratory Tests - Blood
Descrizione

Laboratory Tests - Blood

Has a blood sample been taken?
Descrizione

Has a blood sample been taken?

Tipo di dati

boolean

Date blood sample taken
Descrizione

please fill in only if different from visit date

Tipo di dati

date

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Similar models

Visit 6: Eligibility Check, Laboratory Test

1 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Administrative data
Item
Visit Number
integer
Visit Number
Code List
Visit Number
CL Item
Visit 6 (1)
Item
Day
text
Day
Code List
Day
CL Item
42-56 days after Visit 5 (1)
Subject Number
Item
Subject Number
integer
Date of Visit
Item
Date of Visit
date
Item Group
Check for Study Continuation
Did the subject return for Visit 6?
Item
Did the subject return for Visit 6?
boolean
Item
If No, please tick ONE most appropriate reason
text
If No, please tick ONE most appropriate reason
Code List
If No, please tick ONE most appropriate reason
CL Item
Serious Adverse Event (SAE) (1)
CL Item
Non-Serious Adverse Event (Non-SAE) (2)
CL Item
Other (e.g.withdrawal,protocol violation) (3)
If Other, please specify
Item
If Other, please specify
text
If SAE, record the SAE number
Item
If SAE, record the SAE number
integer
If non-SAE, please record the AE number
Item
If non-SAE, please record the AE number
integer
Item
Please tick who took the decision
text
Please tick who took the decision
Code List
Please tick who took the decision
CL Item
Investigator (1)
CL Item
Parents / Guardians (2)
Item Group
Elimination Criteria During The Study
Item
The following criteria should be checked at each visit subsequent to the first visit.
text
The following criteria should be checked at each visit subsequent to the first visit.
Code List
The following criteria should be checked at each visit subsequent to the first visit.
CL Item
Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s) during the study period (1)
CL Item
Chronic administration (defined as more than 14 days) or immunodepressants or other imminodefying drugs during the study period. (For corticosteroids, this will mean prednisone, or equivalent, ≥0.5 mg/kg/day. Inhaled and topical steroids are allowed.) (2)
Item
1. Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s) during the study period
text
1. Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s) during the study period
Code List
1. Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s) during the study period
CL Item
Applicable (1)
CL Item
Not applicable (2)
Item
2. Chronic administration (defined as more than 14 days) or immunodepressants or other imminodefying drugs during the study period.
text
2. Chronic administration (defined as more than 14 days) or immunodepressants or other imminodefying drugs during the study period.
Code List
2. Chronic administration (defined as more than 14 days) or immunodepressants or other imminodefying drugs during the study period.
CL Item
Applicable (1)
CL Item
Not applicable (2)
Item
3. Administration of a vaccine not foreseen by the study protocol during the period starting from 30 days before each dose of vaccine(s) and ending 30 days after
text
3. Administration of a vaccine not foreseen by the study protocol during the period starting from 30 days before each dose of vaccine(s) and ending 30 days after
Code List
3. Administration of a vaccine not foreseen by the study protocol during the period starting from 30 days before each dose of vaccine(s) and ending 30 days after
CL Item
Applicable (1)
CL Item
Not applicable (2)
Item
4. Administration of immunoglobulins and/or any blood products during the study period
text
4. Administration of immunoglobulins and/or any blood products during the study period
Code List
4. Administration of immunoglobulins and/or any blood products during the study period
CL Item
Applicable (1)
CL Item
Not applicable (2)
Item Group
Laboratory Tests - Blood
Has a blood sample been taken?
Item
Has a blood sample been taken?
boolean
Date blood sample taken
Item
Date blood sample taken
date
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