ID

34983

Description

Study ID: 107022 Clinical Study ID: 107022 Study Title: A phase IIb, controlled, randomised, multicenter, single blind study to demonstrate the Non-Inferiority of the low dose influenza vaccine with or without adjuvant AS03 compared with Fluarix (GlaxoSmithKline Biologicals) administered intramuscularly in elderly >= 60 years Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00321373 Study Link: https://clinicaltrials.gov/ct2/show/NCT00321373 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 2 Study Recruitment Status: Completed Generic Name: Candidate Influenza Vaccine GSK1247446A - 2 different formulations Trade Name: FluarixTM Study Indication: Influenza The purpose of his form is to document if returned for study continuation and should be filled out at visit 2. Visit 1: Day 0, Pre vaccination Visit 2: Day 21, Post vaccination 1 Phone contact: Day 30, post vaccination 1 Visit 3: Day 180, post vaccination 1

Link

https://clinicaltrials.gov/ct2/show/NCT00321373

Keywords

Versions (2)
  1. 2/4/19 2/4/19 -
  2. 2/6/19 2/6/19 -
Copyright Holder

GlaxoSmithKline

Uploaded on

February 6, 2019

DOI

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License

Creative Commons BY-NC 3.0
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Demonstration of the Non-Inferiority of the Low Dose Influenza Vaccine Compared with Fluarix NCT00321373

English

Study Continuation

1 forms  
  1. StudyEvent: ODM
    1. Study Continuation
Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
Subject Number
Description

Subject Number

Data type

integer

Alias
UMLS CUI [1]
C2348585
Date of Visit
Description

Date of Visit

Data type

date

Alias
UMLS CUI [1]
C1320303
Check for Study Continuation
Description

Check for Study Continuation

Alias
UMLS CUI-1
C0805733
UMLS CUI-2
C0008976
UMLS CUI-3
C0042210
Did the subject return for visit 2?
Description

If yes, please complete the next forms, according to the study protocol

Data type

boolean

Alias
UMLS CUI [1,1]
C0008972
UMLS CUI [1,2]
C0805733
Please tick the ONE most appropriate reason and skip the following pages of this visit.
Description

If subject did not return for study continuation

Data type

text

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C0566251
Please specify SAE No.
Description

If SAE was main reason for non-continuation PLease complete and submit SAE report

Data type

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0237753
Please specify AE No. or solicited AE code.
Description

Please complete the Non-Serious Adverse Event section

Data type

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0237753
UMLS CUI [2,1]
C0877248
UMLS CUI [2,2]
C0805701
UMLS CUI [2,3]
C1521902
Other, please specify
Description

e.g.: consent withdrawal, Protocol violation

Data type

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C2348235
Please tick who made the decision
Description

Responsible for Decision

Data type

text

Alias
UMLS CUI [1,1]
C1273518
UMLS CUI [1,2]
C0679006
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Similar models

Study Continuation

1 forms
  1. StudyEvent: ODM
    1. Study Continuation
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Subject Number
Item
Subject Number
integer
C2348585 (UMLS CUI [1])
Date of Visit
Item
Date of Visit
date
C1320303 (UMLS CUI [1])
Item Group
Check for Study Continuation
C0805733 (UMLS CUI-1)
C0008976 (UMLS CUI-2)
C0042210 (UMLS CUI-3)
Study Continuation
Item
Did the subject return for visit 2?
boolean
C0008972 (UMLS CUI [1,1])
C0805733 (UMLS CUI [1,2])
Item
Please tick the ONE most appropriate reason and skip the following pages of this visit.
text
C2348568 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Reason for Non-Continuation
Code List
Please tick the ONE most appropriate reason and skip the following pages of this visit.
CL Item
Seroius Adverse event (SAE)
CL Item
Non-serious advese event (AEX)
CL Item
Other (OTH)
SAE No.
Item
Please specify SAE No.
integer
C1519255 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Non-Serious Adverse Event No.
Item
Please specify AE No. or solicited AE code.
integer
C1518404 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0877248 (UMLS CUI [2,1])
C0805701 (UMLS CUI [2,2])
C1521902 (UMLS CUI [2,3])
Other Specification
Item
Other, please specify
text
C0205394 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Item
Please tick who made the decision
text
C1273518 (UMLS CUI [1,1])
C0679006 (UMLS CUI [1,2])
Responsible for Decision
Code List
Please tick who made the decision
CL Item
Investigator (I)
CL Item
Subject (S)
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