Engelsk

Patient Enrollment Form

1 Formulär  
Patient Enrollment Form
Beskrivning

Patient Enrollment Form

Alias
UMLS CUI-1
C1516879
To
Beskrivning

Please fax this form to the sponsor study contact when the patient has been enroled

Datatyp

text

Alias
UMLS CUI [1]
C2347796
Fax No.
Beskrivning

Clinical Study Sponsor, Fax Number

Datatyp

integer

Alias
UMLS CUI [1,1]
C2347796
UMLS CUI [1,2]
C1549619
The following patient has been enroled in study: 101468/
Beskrivning

Enrollment, Study Identifier

Datatyp

integer

Alias
UMLS CUI [1,1]
C1516879
UMLS CUI [1,2]
C2826693
Patient Initials
Beskrivning

Person Initials

Datatyp

text

Alias
UMLS CUI [1]
C2986440
Patient Number
Beskrivning

Clinical Trial Subject Unique Identifier

Datatyp

integer

Alias
UMLS CUI [1]
C2348585
Centre Number
Beskrivning

Study Coordinating Center, Identification number

Datatyp

integer

Alias
UMLS CUI [1,1]
C2825181
UMLS CUI [1,2]
C1300638
Date of Enrollment
Beskrivning

Enrollment, Date in time

Datatyp

date

Alias
UMLS CUI [1,1]
C1516879
UMLS CUI [1,2]
C0011008
Signed
Beskrivning

Investigator Signature

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Date
Beskrivning

Investigator Signature, Date in time

Datatyp

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Please print name
Beskrivning

Investigator Name

Datatyp

text

Alias
UMLS CUI [1]
C2826892
Institution
Beskrivning

Institution name

Datatyp

text

Alias
UMLS CUI [1]
C1301943
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Similar models

Patient Enrollment Form

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient Enrollment Form
C1516879 (UMLS CUI-1)
Clinical Study Sponsor
Item
To
text
C2347796 (UMLS CUI [1])
Clinical Study Sponsor, Fax Number
Item
Fax No.
integer
C2347796 (UMLS CUI [1,1])
C1549619 (UMLS CUI [1,2])
Enrollment, Study Identifier
Item
The following patient has been enroled in study: 101468/
integer
C1516879 (UMLS CUI [1,1])
C2826693 (UMLS CUI [1,2])
Person Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Clinical Trial Subject Unique Identifier
Item
Patient Number
integer
C2348585 (UMLS CUI [1])
Study Coordinating Center, Identification number
Item
Centre Number
integer
C2825181 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Enrollment, Date in time
Item
Date of Enrollment
date
C1516879 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator Signature
Item
Signed
text
C2346576 (UMLS CUI [1])
Investigator Signature, Date in time
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator Name
Item
Please print name
text
C2826892 (UMLS CUI [1])
Institution name
Item
Institution
text
C1301943 (UMLS CUI [1])
Tillbaka till toppen