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Solicited Adverse Events

1 Formulieren  
Administrative Data
Beschrijving

Administrative Data

Alias
UMLS CUI-1
C1320722
Subject Number
Beschrijving

Subject Number

Datatype

integer

Alias
UMLS CUI [1]
C2348585
Solicited Adverse Events
Beschrijving

Solicited Adverse Events

Alias
UMLS CUI-1
C1457887
UMLS CUI-2
C0042196
UMLS CUI-3
C0877248
Has the subject experienced any of the following signs/symptoms at the administration site during the solicited period?
Beschrijving

If any of these adverse events meets the protocol definition of serious, please complete a Serious Adverse Event report and fax to GSK Biologicals Study Contact for SAE reporting within 24 hours. If "yes" is ticked, please tick No/Yes for each symptom. If Yes is ticked, please complete all items.

Datatype

text

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0042196
UMLS CUI [1,3]
C0877248
Solicited Adverse Events Record - Local Symptoms
Beschrijving

Solicited Adverse Events Record - Local Symptoms

Alias
UMLS CUI-1
C1457887
UMLS CUI-2
C0205276
UMLS CUI-3
C0042196
Local Symptoms
Beschrijving

If redness, swelling or ecchymosis is ticked, provide size in mm. If pain is ticked, provide intensity from 0-3.

Datatype

text

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0205276
Day 0
Beschrijving

Provide size/intensity of pain

Datatype

integer

Alias
UMLS CUI [1]
C0456389
UMLS CUI [2,1]
C0030193
UMLS CUI [2,2]
C0522510
UMLS CUI [3]
C2826182
Day 1
Beschrijving

Provide size/intensity of pain

Datatype

integer

Alias
UMLS CUI [1]
C0456389
UMLS CUI [2,1]
C0030193
UMLS CUI [2,2]
C0522510
UMLS CUI [3]
C2826182
Day 2
Beschrijving

Provide size/intensity of pain

Datatype

integer

Alias
UMLS CUI [1]
C0456389
UMLS CUI [2,1]
C0030193
UMLS CUI [2,2]
C0522510
UMLS CUI [3]
C2826182
Day 3
Beschrijving

Provide size/intensity of pain

Datatype

integer

Alias
UMLS CUI [1]
C0456389
UMLS CUI [2,1]
C0030193
UMLS CUI [2,2]
C0522510
UMLS CUI [3]
C2826182
Day 4
Beschrijving

Provide size/intensity of pain

Datatype

integer

Alias
UMLS CUI [1]
C0456389
UMLS CUI [2,1]
C0030193
UMLS CUI [2,2]
C0522510
UMLS CUI [3]
C2826182
Day 5
Beschrijving

Provide size/intensity of pain

Datatype

integer

Alias
UMLS CUI [1]
C0456389
UMLS CUI [2,1]
C0030193
UMLS CUI [2,2]
C0522510
UMLS CUI [3]
C2826182
Day 6
Beschrijving

Provide size/intensity of pain

Datatype

integer

Alias
UMLS CUI [1]
C0456389
UMLS CUI [2,1]
C0030193
UMLS CUI [2,2]
C0522510
UMLS CUI [3]
C2826182
Ongoing after Day 6?
Beschrijving

Ongoing Symptom

Datatype

boolean

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C3174772
Date of Last Day of Symptoms
Beschrijving

Date of Last Day of Symptoms

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1517741
UMLS CUI [1,3]
C1457887
Solicited Adverse Events - General Symptoms
Beschrijving

Solicited Adverse Events - General Symptoms

Alias
UMLS CUI-1
C0159028
UMLS CUI-2
C0042196
UMLS CUI-3
C0877248
Has the subject experienced any of the following signs/symptoms during the solicited period?
Beschrijving

If yes, please tick No/Yes for each symptom. If Yes is ticked, please complete all items.

Datatype

text

Alias
UMLS CUI [1,1]
C0159028
UMLS CUI [1,2]
C0042196
UMLS CUI [1,3]
C0877248
Solicited Adverse Events Record - General Symptoms
Beschrijving

Solicited Adverse Events Record - General Symptoms

Alias
UMLS CUI-1
C0159028
UMLS CUI-2
C0042196
UMLS CUI-3
C0877248
General Symptom
Beschrijving

If any of these adverse events meets the protocol definition of serious, please complete a Serious Adverse Event report and fax to GSK Biologicals Study Contact for SAE reporting within 24 hours. arthralgia = joint pain

Datatype

text

Alias
UMLS CUI [1]
C0159028
Day 0
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 1
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 2
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 3
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 4
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 5
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 6
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Ongoing after Day 6?
Beschrijving

Ongoing Symptom

Datatype

boolean

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C3174772
Date of Last Day of Symptoms
Beschrijving

Date of Last Day of Symptoms

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1517741
UMLS CUI [1,3]
C1457887
Causality?
Beschrijving

Causality

Datatype

boolean

Alias
UMLS CUI [1]
C0015127
Solicited Adverse Events - Fever
Beschrijving

Solicited Adverse Events - Fever

Fever
Beschrijving

Fever

Datatype

boolean

Alias
UMLS CUI [1]
C0015967
Fever Measurement Route
Beschrijving

If fever is ticked

Datatype

text

Alias
UMLS CUI [1,1]
C0449687
UMLS CUI [1,2]
C0015967
Day 0
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 1
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 2
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 3
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 4
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 5
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Day 6
Beschrijving

Provide intensity of fatigue, headache, musle ach, shivering or arthralgia

Datatype

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826182
Ongoing after Day 6?
Beschrijving

Ongoing Symptom

Datatype

boolean

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C3174772
Date of Last Day of Symptoms
Beschrijving

Date of Last Day of Symptoms

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1517741
UMLS CUI [1,3]
C1457887
Causality?
Beschrijving

Causality

Datatype

boolean

Alias
UMLS CUI [1]
C0015127
Unsolicited Adverse Events
Beschrijving

Unsolicited Adverse Events

Alias
UMLS CUI-1
C0877248
UMLS CUI-2
C0042196
Has the subject experienced any serious or non-serious unsolicited adverse events from Visit 1 to Visit 2?
Beschrijving

If yes, Fill in the Non-Serious Adverse Event section or Serious Adverse Event report, as appropriate.

Datatype

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0042196
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Similar models

Solicited Adverse Events

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Subject Number
Item
Subject Number
integer
C2348585 (UMLS CUI [1])
Item Group
Solicited Adverse Events
C1457887 (UMLS CUI-1)
C0042196 (UMLS CUI-2)
C0877248 (UMLS CUI-3)
Item
Has the subject experienced any of the following signs/symptoms at the administration site during the solicited period?
text
C1457887 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0877248 (UMLS CUI [1,3])
Solicited Adverse Events
Code List
Has the subject experienced any of the following signs/symptoms at the administration site during the solicited period?
CL Item
Information not available (U)
CL Item
No Vaccine administered (NA)
CL Item
No (N)
CL Item
Yes (Y)
Item Group
Solicited Adverse Events Record - Local Symptoms
C1457887 (UMLS CUI-1)
C0205276 (UMLS CUI-2)
C0042196 (UMLS CUI-3)
Item
Local Symptoms
text
C1457887 (UMLS CUI [1,1])
C0205276 (UMLS CUI [1,2])
Local Symptoms
Code List
Local Symptoms
CL Item
Redness (RE)
CL Item
Swelling (SW)
CL Item
Ecchymosis (EC)
CL Item
Pain (PA)
Day 0
Item
Day 0
integer
C0456389 (UMLS CUI [1])
C0030193 (UMLS CUI [2,1])
C0522510 (UMLS CUI [2,2])
C2826182 (UMLS CUI [3])
Day 1
Item
Day 1
integer
C0456389 (UMLS CUI [1])
C0030193 (UMLS CUI [2,1])
C0522510 (UMLS CUI [2,2])
C2826182 (UMLS CUI [3])
Day 2
Item
Day 2
integer
C0456389 (UMLS CUI [1])
C0030193 (UMLS CUI [2,1])
C0522510 (UMLS CUI [2,2])
C2826182 (UMLS CUI [3])
Day 3
Item
Day 3
integer
C0456389 (UMLS CUI [1])
C0030193 (UMLS CUI [2,1])
C0522510 (UMLS CUI [2,2])
C2826182 (UMLS CUI [3])
Day 4
Item
Day 4
integer
C0456389 (UMLS CUI [1])
C0030193 (UMLS CUI [2,1])
C0522510 (UMLS CUI [2,2])
C2826182 (UMLS CUI [3])
Day 5
Item
Day 5
integer
C0456389 (UMLS CUI [1])
C0030193 (UMLS CUI [2,1])
C0522510 (UMLS CUI [2,2])
C2826182 (UMLS CUI [3])
Day 6
Item
Day 6
integer
C0456389 (UMLS CUI [1])
C0030193 (UMLS CUI [2,1])
C0522510 (UMLS CUI [2,2])
C2826182 (UMLS CUI [3])
Ongoing Symptom
Item
Ongoing after Day 6?
boolean
C1457887 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
Date of Last Day of Symptoms
Item
Date of Last Day of Symptoms
date
C0011008 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C1457887 (UMLS CUI [1,3])
Item Group
Solicited Adverse Events - General Symptoms
C0159028 (UMLS CUI-1)
C0042196 (UMLS CUI-2)
C0877248 (UMLS CUI-3)
Item
Has the subject experienced any of the following signs/symptoms during the solicited period?
text
C0159028 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0877248 (UMLS CUI [1,3])
Solicited Adverse Events - General Symptoms
Code List
Has the subject experienced any of the following signs/symptoms during the solicited period?
CL Item
Information not available (U)
CL Item
No Vaccine administered (NA)
CL Item
No (N)
CL Item
Yes (Y)
Item Group
Solicited Adverse Events Record - General Symptoms
C0159028 (UMLS CUI-1)
C0042196 (UMLS CUI-2)
C0877248 (UMLS CUI-3)
Item
General Symptom
text
C0159028 (UMLS CUI [1])
General Symptom
Code List
General Symptom
CL Item
Fatigue (FA)
CL Item
Headache (HE)
CL Item
Muscle Ache (MH)
CL Item
Shivering (SH)
CL Item
Arthralgia (AR)
Day 0
Item
Day 0
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 1
Item
Day 1
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 2
Item
Day 2
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 3
Item
Day 3
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 4
Item
Day 4
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 5
Item
Day 5
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 6
Item
Day 6
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Ongoing Symptom
Item
Ongoing after Day 6?
boolean
C1457887 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
Date of Last Day of Symptoms
Item
Date of Last Day of Symptoms
date
C0011008 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C1457887 (UMLS CUI [1,3])
Causality
Item
Causality?
boolean
C0015127 (UMLS CUI [1])
Item Group
Solicited Adverse Events - Fever
Fever
Item
Fever
boolean
C0015967 (UMLS CUI [1])
Item
Fever Measurement Route
text
C0449687 (UMLS CUI [1,1])
C0015967 (UMLS CUI [1,2])
Fever Measurement Route
Code List
Fever Measurement Route
CL Item
Axillary (A)
CL Item
Oral (O)
CL Item
Rectal (R)
Day 0
Item
Day 0
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 1
Item
Day 1
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 2
Item
Day 2
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 3
Item
Day 3
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 4
Item
Day 4
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 5
Item
Day 5
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Day 6
Item
Day 6
integer
C0518690 (UMLS CUI [1,1])
C2826182 (UMLS CUI [1,2])
Ongoing Symptom
Item
Ongoing after Day 6?
boolean
C1457887 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
Date of Last Day of Symptoms
Item
Date of Last Day of Symptoms
date
C0011008 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C1457887 (UMLS CUI [1,3])
Causality
Item
Causality?
boolean
C0015127 (UMLS CUI [1])
Item Group
Unsolicited Adverse Events
C0877248 (UMLS CUI-1)
C0042196 (UMLS CUI-2)
Item
Has the subject experienced any serious or non-serious unsolicited adverse events from Visit 1 to Visit 2?
text
C0877248 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
Unsolicited Adverse Events
Code List
Has the subject experienced any serious or non-serious unsolicited adverse events from Visit 1 to Visit 2?
CL Item
Information not available (U)
CL Item
No vaccine administered (NA)
CL Item
No (N)
CL Item
Yes (Y)
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