Englisch

Vaccine administration, Randomization/ Treatment allocation

1 Formulare  
Administrative data
Beschreibung

Administrative data

Alias
UMLS CUI-1
C1320722
Subject Number
Beschreibung

Subject Number

Datentyp

text

Alias
UMLS CUI [1]
C2348585
Visit type
Beschreibung

Visit type

Datentyp

integer

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C0332307
Visit date
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1]
C1320303
Randomisation/ Treatment Allocation
Beschreibung

Randomisation/ Treatment Allocation

Alias
UMLS CUI-1
C0034656
Record treatment number
Beschreibung

Treatment number

Datentyp

text

Alias
UMLS CUI [1,1]
C1522541
UMLS CUI [1,2]
C0600091
Vaccine administration
Beschreibung

Vaccine administration

Alias
UMLS CUI-1
C2368628
Date if different from visit date
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2368628
Pre-Vaccination temperature (°C)
Beschreibung

Choose either this unit of measurement OR °F in the following item.

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C0332152
UMLS CUI [1,3]
C0042196
°C
Pre-Vaccination temperature (°F)
Beschreibung

Choose either this unit of measurement OR °C in the item above.

Datentyp

float

Maßeinheiten
  • °F
Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C0332152
UMLS CUI [1,3]
C0042196
°F
Route of measurement
Beschreibung

Route of measurement

Datentyp

text

Alias
UMLS CUI [1,1]
C0886414
UMLS CUI [1,2]
C0449444
Vaccine administration
Beschreibung

If any adverse events occurred during the immediate post-vaccination time (30 minutes) please fill in the Solicited Adverse Events section, the Non-Serious Adverse Event section or a Serious Adverse Event report. Wrong vial number: Option for visit 3 only.

Datentyp

integer

Alias
UMLS CUI [1]
C2368628
Replacement vial identifier
Beschreibung

Replacement vial identifier

Datentyp

text

Alias
UMLS CUI [1,1]
C0184301
UMLS CUI [1,2]
C0559956
UMLS CUI [1,3]
C0600091
Wrong vial number
Beschreibung

Only to fill in for Visit 3.

Datentyp

integer

Alias
UMLS CUI [1,1]
C0184301
UMLS CUI [1,2]
C0600091
UMLS CUI [1,3]
C3827420
Side/ Site of vaccine administration
Beschreibung

According to the protocol: Take the non dominant side. Take deltoid I.M. as route for vaccine administration

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C0441987
UMLS CUI [2]
C0013153
Has the study vaccine been administered according to the Protocol?
Beschreibung

According to the protocol: The vaccine was administered in deltoid I.M of the non dominant side.

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C2348563
If study vaccine has been NOT administered according to the Protocol, please tick the side that apply
Beschreibung

No protocol vaccine administration: Side

Datentyp

text

Alias
UMLS CUI [1,1]
C1518384
UMLS CUI [1,2]
C2368628
UMLS CUI [1,3]
C0441987
If study vaccine has been NOT administered according to the Protocol, please tick the site (anatomic structure) that apply
Beschreibung

No protocol vaccine administration: Anatomic structure

Datentyp

integer

Alias
UMLS CUI [1,1]
C1518384
UMLS CUI [1,2]
C2368628
UMLS CUI [1,3]
C0700276
If study vaccine has been NOT administered according to the Protocol, please tick the route of administration that apply
Beschreibung

No protocol vaccine administration: Route of administration

Datentyp

text

Alias
UMLS CUI [1,1]
C1518384
UMLS CUI [1,2]
C2368628
UMLS CUI [1,3]
C0013153
Comment
Beschreibung

If study vaccine has been NOT administered according to the Protocol, please comment if necessary.

Datentyp

text

Alias
UMLS CUI [1]
C0947611
No vaccine administration
Beschreibung

No vaccine administration

Alias
UMLS CUI-1
C2368628
UMLS CUI-2
C1272696
If vaccine administration was not done, please tick the major reason for non administration of vaccine
Beschreibung

If you tick SAE: Please complete and submit SAE report. If you tick AEX: Please complete Non-serious Adverse Event section.

Datentyp

text

Alias
UMLS CUI [1,1]
C2368628
UMLS CUI [1,2]
C1272696
UMLS CUI [1,3]
C1549995
If you ticked SAE as primary reason for non administration of vaccine, please specify SAE Number.
Beschreibung

SAE Number

Datentyp

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0237753
If you ticked AE as primary reason for non administration of vaccine, please specify AE Number.
Beschreibung

AE Number

Datentyp

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0237753
If you ticked other reason as primary reason for non administration of vaccine, please specify.
Beschreibung

(e.g.: consent withdrawal, Protocol violation, …) If any prophylactic antipyretics are administred it is considered as a Protocol violation

Datentyp

text

Alias
UMLS CUI [1,1]
C3840932
UMLS CUI [1,2]
C2368628
UMLS CUI [1,3]
C1272696
Please tick who made the decision
Beschreibung

Decision taken

Datentyp

text

Alias
UMLS CUI [1,1]
C0679006
UMLS CUI [1,2]
C2368628
UMLS CUI [1,3]
C1272696
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Ähnliche Modelle

Vaccine administration, Randomization/ Treatment allocation

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Subject Number
Item
Subject Number
text
C2348585 (UMLS CUI [1])
Item
Visit type
integer
C0545082 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Visit type
Code List
Visit type
CL Item
Visit 1 (1)
CL Item
Visit 3 (2)
Visit date
Item
Visit date
date
C1320303 (UMLS CUI [1])
Item Group
Randomisation/ Treatment Allocation
C0034656 (UMLS CUI-1)
Treatment number
Item
Record treatment number
text
C1522541 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Item Group
Vaccine administration
C2368628 (UMLS CUI-1)
Date of vaccine administration
Item
Date if different from visit date
date
C0011008 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
Pre-Vaccination temperature (°C)
Item
Pre-Vaccination temperature (°C)
float
C0005903 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0042196 (UMLS CUI [1,3])
Pre-Vaccination temperature (°F)
Item
Pre-Vaccination temperature (°F)
float
C0005903 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0042196 (UMLS CUI [1,3])
Item
Route of measurement
text
C0886414 (UMLS CUI [1,1])
C0449444 (UMLS CUI [1,2])
Route of measurement
Code List
Route of measurement
CL Item
Axillary (A)
CL Item
Oral (mandatory) (O)
CL Item
Rectal (R)
Item
Vaccine administration
integer
C2368628 (UMLS CUI [1])
Vaccine administration
Code List
Vaccine administration
CL Item
Pandemic Influenza Test Vaccine (1)
CL Item
replacement vial (2)
CL Item
Wrong viel number (3)
CL Item
Not administered (4)
Replacement vial identifier
Item
Replacement vial identifier
text
C0184301 (UMLS CUI [1,1])
C0559956 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Wrong vial number
Item
Wrong vial number
integer
C0184301 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C3827420 (UMLS CUI [1,3])
Item
Side/ Site of vaccine administration
text
C2368628 (UMLS CUI [1,1])
C0441987 (UMLS CUI [1,2])
C0013153 (UMLS CUI [2])
Side/ Site of vaccine administration
Code List
Side/ Site of vaccine administration
CL Item
Left (L)
CL Item
Right (R)
Item
Has the study vaccine been administered according to the Protocol?
text
C2368628 (UMLS CUI [1,1])
C2348563 (UMLS CUI [1,2])
Protocol vaccine administration
Code List
Has the study vaccine been administered according to the Protocol?
CL Item
Yes (Y)
CL Item
No (N)
Item
If study vaccine has been NOT administered according to the Protocol, please tick the side that apply
text
C1518384 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
C0441987 (UMLS CUI [1,3])
Protocol vaccine administration
Code List
If study vaccine has been NOT administered according to the Protocol, please tick the side that apply
CL Item
Non dominant (N)
CL Item
Dominant (D)
Item
If study vaccine has been NOT administered according to the Protocol, please tick the site (anatomic structure) that apply
integer
C1518384 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
C0700276 (UMLS CUI [1,3])
Protocol vaccine administration
Code List
If study vaccine has been NOT administered according to the Protocol, please tick the site (anatomic structure) that apply
CL Item
Deltoid (1)
CL Item
Thigh (2)
CL Item
Buttock (3)
Item
If study vaccine has been NOT administered according to the Protocol, please tick the route of administration that apply
text
C1518384 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
C0013153 (UMLS CUI [1,3])
Protocol vaccine administration
Code List
If study vaccine has been NOT administered according to the Protocol, please tick the route of administration that apply
CL Item
I.M (M)
CL Item
S.C. (SC)
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Item Group
No vaccine administration
C2368628 (UMLS CUI-1)
C1272696 (UMLS CUI-2)
Item
If vaccine administration was not done, please tick the major reason for non administration of vaccine
text
C2368628 (UMLS CUI [1,1])
C1272696 (UMLS CUI [1,2])
C1549995 (UMLS CUI [1,3])
Primary reason for non administration of vaccine
Code List
If vaccine administration was not done, please tick the major reason for non administration of vaccine
CL Item
Serious adverse event (SAE)
CL Item
Non-Serious adverse event (AEX)
CL Item
Other (OTH)
SAE Number
Item
If you ticked SAE as primary reason for non administration of vaccine, please specify SAE Number.
integer
C1519255 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
AE Number
Item
If you ticked AE as primary reason for non administration of vaccine, please specify AE Number.
integer
C1518404 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Other reason
Item
If you ticked other reason as primary reason for non administration of vaccine, please specify.
text
C3840932 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
C1272696 (UMLS CUI [1,3])
Item
Please tick who made the decision
text
C0679006 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
C1272696 (UMLS CUI [1,3])
Decision taken
Code List
Please tick who made the decision
CL Item
Investigator (I)
CL Item
Subject (S)
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