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104727 (DTPW-HBV=HIB-MENAC-TT-016 BST 013 (15/24M)) - Concomitant Vaccination; Medication, Non- serious Adverse Events; Study Conclusion

1 Formulär  
Concomitant Vaccination
Beskrivning

Concomitant Vaccination

Alias
UMLS CUI-1
C0042196
UMLS CUI-2
C2347852
Has any vaccine other than the study vaccine(s) been administered during the timeframe as specified in the protocol?
Beskrivning

If yes, please record concomitant vaccination with trade name and/ or generic name, route and vaccine administration date.

Datatyp

boolean

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C0205394
Concomitant Vaccination
Beskrivning

Concomitant Vaccination

Alias
UMLS CUI-1
C0042196
UMLS CUI-2
C2347852
Trade/ (Generic) Name
Beskrivning

Trade/ (Generic) Name

Datatyp

text

Alias
UMLS CUI [1]
C2360065
UMLS CUI [2]
C0592502
Medication Administration route
Beskrivning

Medication Administration route

Datatyp

text

Alias
UMLS CUI [1]
C0013153
Administration date
Beskrivning

Administration date

Datatyp

date

Alias
UMLS CUI [1,1]
C1533734
UMLS CUI [1,2]
C0011008
Medication
Beskrivning

Medication

Alias
UMLS CUI-1
C0013227
Has any medications/ treatments been administered during study protocol?
Beskrivning

If yes, please complete the following table.

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0087111
UMLS CUI [1,3]
C0347984
UMLS CUI [1,4]
C2603343
Medication
Beskrivning

Medication

Alias
UMLS CUI-1
C0013227
Trade/ Generic Name
Beskrivning

Trade/ Generic Name

Datatyp

text

Alias
UMLS CUI [1,1]
C2360065
UMLS CUI [1,2]
C0592502
Medical Indication
Beskrivning

Medical Indication

Datatyp

integer

Alias
UMLS CUI [1,1]
C3146298
UMLS CUI [1,2]
C0013227
Total daily dose
Beskrivning

Total daily dose

Datatyp

text

Alias
UMLS CUI [1,1]
C2348070
UMLS CUI [1,2]
C0439810
Medication Administration Route
Beskrivning

Medication Administration Route

Datatyp

text

Alias
UMLS CUI [1]
C0013153
Medication Start Date
Beskrivning

Medication Start Date

Datatyp

date

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0808070
Medication Stop Date
Beskrivning

Medication Stop Date

Datatyp

date

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0806020
Medication continuing at end of study
Beskrivning

Medication continuing at end of study

Datatyp

integer

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0549178
UMLS CUI [2,1]
C0008976
UMLS CUI [2,2]
C0444930
Non- serious Adverse Event
Beskrivning

Non- serious Adverse Event

Alias
UMLS CUI-1
C1518404
Has any non- serious adverse event occured within one month (minimum 30 days) post- vaccination, excluding those recorded on the Solicited Adverse Events pages?
Beskrivning

Has any non- serious adverse event occured within one month post- vaccination?

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C2368628
UMLS CUI [1,3]
C0687676
Non- serious Adverse Event
Beskrivning

Non- serious Adverse Event

Alias
UMLS CUI-1
C1518404
Non- serious adverse event Description
Beskrivning

Non- serious adverse event Description

Datatyp

text

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0678257
Administration site or Non- administration site?
Beskrivning

Administration site or Non- administration site?

Datatyp

text

Alias
UMLS CUI [1,1]
C1515974
UMLS CUI [1,2]
C0013153
UMLS CUI [1,3]
C0042210
If Adverse event on Administration site, specify
Beskrivning

If Adverse event on Administration site, specify

Datatyp

integer

Alias
UMLS CUI [1,1]
C1515974
UMLS CUI [1,2]
C0013153
UMLS CUI [1,3]
C0042210
UMLS CUI [1,4]
C2348235
Start Date Non- serious Adverse Event
Beskrivning

Start Date Non- serious Adverse Event

Datatyp

date

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0808070
Start Date Non- serious Adverse Event during immediate post- vaccination period (30 minutes)?
Beskrivning

Start Date Non- serious Adverse Event during immediate post- vaccination period (30 minutes)?

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0808070
UMLS CUI [1,3]
C2368628
UMLS CUI [1,4]
C0687676
Stop Date Non- serious Adverse Event
Beskrivning

Stop Date Non- serious Adverse Event

Datatyp

date

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0806020
Non- serious Adverse Event Intensity
Beskrivning

Non- serious Adverse Event Intensity

Datatyp

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0518690
Relationship to investigatoinal products
Beskrivning

Is there a reasonable possibility that the AE may have been caused by the investigational product?

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0013230
UMLS CUI [1,3]
C0439849
Non- serious Adverse Event Outcome + integer
Beskrivning

Non- serious Adverse Event Outcome

Datatyp

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C1705586
Medically attended visit
Beskrivning

If yes, please specify type.

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C1386497
Medically attended visit specification
Beskrivning

Medically attended visit specification

Datatyp

text

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C1386497
UMLS CUI [1,3]
C2348235
Study Conclusion
Beskrivning

Study Conclusion

Alias
UMLS CUI-1
C1707478
UMLS CUI-2
C0008972
Did the subject experience any Serious Adverse Event during the study period?
Beskrivning

Did the subject experience any Serious Adverse Event during the study period?

Datatyp

boolean

Alias
UMLS CUI [1]
C1519255
If subject experiences Serious Adverse Event, specify total number of Serious Adverse Events
Beskrivning

Total number of Serious Adverse Events

Datatyp

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0449788
Did any elimination criteria become applicable during the study?
Beskrivning

Did any elimination criteria become applicable during the study?

Datatyp

boolean

Alias
UMLS CUI [1]
C0680251
Specify elimination criteria
Beskrivning

Specify elimination criteria

Datatyp

text

Alias
UMLS CUI [1,1]
C0680251
UMLS CUI [1,2]
C2348235
Was the subject withdrawn from study?
Beskrivning

Was the subject withdrawn from study?

Datatyp

boolean

Alias
UMLS CUI [1]
C0422727
Major reason for withdrawal (tick ONE box only)
Beskrivning

Major reason for withdrawal

Datatyp

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0392360
If reason for withdrawal is Non- serious Adverse Event, specify.
Beskrivning

If reason for withdrawal is Non- serious Adverse Event, specify.

Datatyp

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0392360
UMLS CUI [2]
C1518404
If reason for withdrawal is protocol violation, specify.
Beskrivning

If reason for withdrawal is protocol violation, specify

Datatyp

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0392360
UMLS CUI [2]
C1709750
If other reason for withdrawal, specify
Beskrivning

If other reason for withdrawal, specify

Datatyp

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0392360
UMLS CUI [1,3]
C0205394
UMLS CUI [1,4]
C2348235
Please tick, who made the decision
Beskrivning

Please tick, who made the decision

Datatyp

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0679006
Date of last contact
Beskrivning

Date of last contact

Datatyp

date

Alias
UMLS CUI [1]
C0805839
Was the subject in good condition at date of last contact?
Beskrivning

If no, please give details within the Adverse Events section.

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1142435
UMLS CUI [1,2]
C0681850
UMLS CUI [1,3]
C0805839
Investigator's signature
Beskrivning

Investigator's signature

Alias
UMLS CUI-1
C2346576
Investigator's signature
Beskrivning

I confirm that I have reviewed the date in this Case Report Form for this subject. All information entered by myself or my colleagues is, to the best of my knowledge, complete and accurate, as of the date below.

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Printed Investigator's name
Beskrivning

Printed Investigator's name

Datatyp

text

Alias
UMLS CUI [1]
C2826892
Investigator's signature date
Beskrivning

Investigator's signature date

Datatyp

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
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Similar models

104727 (DTPW-HBV=HIB-MENAC-TT-016 BST 013 (15/24M)) - Concomitant Vaccination; Medication, Non- serious Adverse Events; Study Conclusion

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Concomitant Vaccination
C0042196 (UMLS CUI-1)
C2347852 (UMLS CUI-2)
Has any vaccine other than the study vaccine(s) been administered?
Item
Has any vaccine other than the study vaccine(s) been administered during the timeframe as specified in the protocol?
boolean
C2368628 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Concomitant Vaccination
C0042196 (UMLS CUI-1)
C2347852 (UMLS CUI-2)
Trade/ (Generic) Name
Item
Trade/ (Generic) Name
text
C2360065 (UMLS CUI [1])
C0592502 (UMLS CUI [2])
Item
Medication Administration route
text
C0013153 (UMLS CUI [1])
Medication Administration route
Code List
Medication Administration route
CL Item
Intradermal (ID)
CL Item
Inhalation (IH)
CL Item
Intramuscular (IM)
CL Item
Intravenous (IV)
CL Item
Intranasal (NA)
CL Item
Other (OTH)
CL Item
Parenteral (PE)
CL Item
Oral (PO)
CL Item
SC Subcutaneous (SC Subcutaneous)
CL Item
Sublingual (SL)
CL Item
Transdermal (TD)
CL Item
Unknown (UNK)
Administration date
Item
Administration date
date
C1533734 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
Medication
C0013227 (UMLS CUI-1)
Has any medications/ treatments been administered during study protocol?
Item
Has any medications/ treatments been administered during study protocol?
boolean
C0013227 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C0347984 (UMLS CUI [1,3])
C2603343 (UMLS CUI [1,4])
Item Group
Medication
C0013227 (UMLS CUI-1)
Trade/ Generic Name
Item
Trade/ Generic Name
text
C2360065 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Item
Medical Indication
integer
C3146298 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Medical Indication
Code List
Medical Indication
CL Item
Prophylactic (1)
Total daily dose
Item
Total daily dose
text
C2348070 (UMLS CUI [1,1])
C0439810 (UMLS CUI [1,2])
Medication Administration Route
Item
Medication Administration Route
text
C0013153 (UMLS CUI [1])
Medication Start Date
Item
Medication Start Date
date
C0013227 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Medication Stop Date
Item
Medication Stop Date
date
C0013227 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Item
Medication continuing at end of study
integer
C0013227 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
C0008976 (UMLS CUI [2,1])
C0444930 (UMLS CUI [2,2])
Medication continuing at end of study
Code List
Medication continuing at end of study
CL Item
Medication continuing (1)
Item Group
Non- serious Adverse Event
C1518404 (UMLS CUI-1)
Has any non- serious adverse event occured within one month post- vaccination?
Item
Has any non- serious adverse event occured within one month (minimum 30 days) post- vaccination, excluding those recorded on the Solicited Adverse Events pages?
boolean
C1518404 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
C0687676 (UMLS CUI [1,3])
Item Group
Non- serious Adverse Event
C1518404 (UMLS CUI-1)
Non- serious adverse event Description
Item
Non- serious adverse event Description
text
C1518404 (UMLS CUI [1,1])
C0678257 (UMLS CUI [1,2])
Item
Administration site or Non- administration site?
text
C1515974 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,3])
Administration site or Non- administration site?
Code List
Administration site or Non- administration site?
CL Item
Administration site  (L)
CL Item
Non- administration site (G)
Item
If Adverse event on Administration site, specify
integer
C1515974 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
If Adverse event on Administration site, specify
Code List
If Adverse event on Administration site, specify
CL Item
DTPw-HBV/Hib-MenAC vaccine (111)
CL Item
DTPw-HBV/Hib vaccine (94)
CL Item
Meningitec vaccine (109)
Start Date Non- serious Adverse Event
Item
Start Date Non- serious Adverse Event
date
C1518404 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Start Date Non- serious Adverse Event during immediate post- vaccination period (30 minutes)?
Item
Start Date Non- serious Adverse Event during immediate post- vaccination period (30 minutes)?
boolean
C1518404 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
C2368628 (UMLS CUI [1,3])
C0687676 (UMLS CUI [1,4])
Stop Date Non- serious Adverse Event
Item
Stop Date Non- serious Adverse Event
date
C1518404 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Item
Non- serious Adverse Event Intensity
integer
C1518404 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Non- serious Adverse Event Intensity
Code List
Non- serious Adverse Event Intensity
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Relationship to investigatoinal products
Item
Relationship to investigatoinal products
boolean
C1518404 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Item
Non- serious Adverse Event Outcome + integer
integer
C1518404 (UMLS CUI [1,1])
C1705586 (UMLS CUI [1,2])
Non- serious Adverse Event Outcome
Code List
Non- serious Adverse Event Outcome + integer
CL Item
Recovered/ Resolved  (1)
CL Item
Recovering/ Resolving  (2)
CL Item
Not recovered/ not resolved  (3)
CL Item
Recovered with sequelae/ Resolved with sequelae (4)
Medically attended visit
Item
Medically attended visit
boolean
C0545082 (UMLS CUI [1,1])
C1386497 (UMLS CUI [1,2])
Item
Medically attended visit specification
text
C0545082 (UMLS CUI [1,1])
C1386497 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Medically attended visit specification
Code List
Medically attended visit specification
CL Item
Hospitalisation  (HO)
CL Item
Emergency Room  (ER)
CL Item
Medical Personnel (MD)
Item Group
Study Conclusion
C1707478 (UMLS CUI-1)
C0008972 (UMLS CUI-2)
Did the subject experience any Serious Adverse Event during the study period?
Item
Did the subject experience any Serious Adverse Event during the study period?
boolean
C1519255 (UMLS CUI [1])
Total number of Serious Adverse Events
Item
If subject experiences Serious Adverse Event, specify total number of Serious Adverse Events
integer
C1519255 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Did any elimination criteria become applicable during the study?
Item
Did any elimination criteria become applicable during the study?
boolean
C0680251 (UMLS CUI [1])
Specify elimination criteria
Item
Specify elimination criteria
text
C0680251 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Was the subject withdrawn from study?
Item
Was the subject withdrawn from study?
boolean
C0422727 (UMLS CUI [1])
Item
Major reason for withdrawal (tick ONE box only)
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Major reason for withdrawal
Code List
Major reason for withdrawal (tick ONE box only)
CL Item
Serious adverse event (SAE)
CL Item
Non- serious adverse event (complete Non- serious Adverse Event section), please specify (AEX)
CL Item
Protocol violation, please specify (PTV)
CL Item
Consent withdrawal, not due to an adverse event (CWS)
CL Item
Migrated/ moved from the study area (MIG)
CL Item
Lost to follow- up (LFU)
CL Item
Other, please specify (OTH)
If reason for withdrawal is Non- serious Adverse Event, specify.
Item
If reason for withdrawal is Non- serious Adverse Event, specify.
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C1518404 (UMLS CUI [2])
If reason for withdrawal is protocol violation, specify
Item
If reason for withdrawal is protocol violation, specify.
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C1709750 (UMLS CUI [2])
If other reason for withdrawal, specify
Item
If other reason for withdrawal, specify
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
Item
Please tick, who made the decision
text
C0422727 (UMLS CUI [1,1])
C0679006 (UMLS CUI [1,2])
Please tick, who made the decision
Code List
Please tick, who made the decision
CL Item
Investigator  (I)
CL Item
Parents/ Guardians (P)
Date of last contact
Item
Date of last contact
date
C0805839 (UMLS CUI [1])
Was the subject in good condition at date of last contact?
Item
Was the subject in good condition at date of last contact?
boolean
C1142435 (UMLS CUI [1,1])
C0681850 (UMLS CUI [1,2])
C0805839 (UMLS CUI [1,3])
Item Group
Investigator's signature
C2346576 (UMLS CUI-1)
Investigator's signature
Item
Investigator's signature
text
C2346576 (UMLS CUI [1])
Printed Investigator's name
Item
Printed Investigator's name
text
C2826892 (UMLS CUI [1])
Investigator's signature date
Item
Investigator's signature date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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