Pharmacogenetic Research Consent
Item
Has informed consent been obtained for PGx-Pharmacogenetic research?
boolean
Date and Time of Informed Consent
Item
Date and Time of Informed Consent
datetime
blood sample
Item
Has a blood sample been collected for PGx-pharmacogenetic (DNA) research?
boolean
Date Sample Taken
Item
Record the date sample taken
date
Item
In case of no consent, record the reason
text
Code List
In case of no consent, record the reason
CL Item
Subject declined (1)
CL Item
Subject not asked by Investigator (2)
Specify Other
Item
If other, please specify
text
Has subject withdrawn consent for PGx-Pharmacogenetic research?
Item
Has subject withdrawn consent for PGx-Pharmacogenetic research?
boolean
Has a request been made for sample destruction?
Item
Has a request been made for sample destruction?
boolean
Item
If Yes, enter the reason
text
Code List
If Yes, enter the reason
CL Item
Subject requested (1)
If Other, specify
Item
If Other, specify
text
Investogator's Confirmation
Item
By my dated signature below I verify that this case report form accurately displays the results of the examinations, tests, evaluations and treatment noted within.
date
Investigator's signature
Item
Investigator's signature
text
Investigator's name (Print)
Item
Investigator's name (Print)
text