Date of visit
Item
Date of Visit
date
C1320303 (UMLS CUI [1])
Clinical Trial Subject Unique Identifier
Item
Subject Number
integer
C2348585 (UMLS CUI [1])
Institution name, Identifier
Item
Center number
integer
C1301943 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Patient date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Gender
text
C0079399 (UMLS CUI [1])
Item
Race
text
C0034510 (UMLS CUI [1])
CL Item
Arabic/North African (2)
CL Item
White/Caucasian (3)
CL Item
East & South East Asian (4)
CL Item
American Hispanic (6)
CL Item
Other, please specify (8)
Body Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Body Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Eligibility Determination
Item
Did the subject meet all the entry criteria ?
boolean
C0013893 (UMLS CUI [1])
Compliance behavior, Study Protocol
Item
Subjects for whom the investigator believes that their parents/guardians can and will comply with the requirements of the protocol (e.g., completion of the diary cards, return for follow- up visits) should be enrolled in the study.
boolean
C1321605 (UMLS CUI [1,1])
C2348563 (UMLS CUI [1,2])
Gender; Age
Item
A male or female between, and including, 6 and 12 weeks of age at the time of the first vaccination.
boolean
C0079399 (UMLS CUI [1])
C0001779 (UMLS CUI [2])
Informed Consent
Item
Written informed consent obtained from the parent or guardian of the subject.
boolean
C0021430 (UMLS CUI [1])
Health Status
Item
Free of obvious health problems as established by medical history and clinical examination before entering into the study.
boolean
C0018759 (UMLS CUI [1])
Duration of gestation
Item
Born after a gestation period between 36 and 42 weeks.
boolean
C0460089 (UMLS CUI [1])
Concomitant Agent
Item
Use of any investigational or non-registered product (drug or vaccine) other than the study vaccine(s) within 30 days preceding the first dose of study vaccine, or planned use during the study period.
boolean
C2347852 (UMLS CUI [1])
Immunosuppressants; non-specific immune-modulator therapy
Item
Chronic administration (defined as more than 14 days) of immunosuppressants or other immune-modifying drugs since birth. (For corticosteroids, this will mean prednisone, or equivalent, ≥ 0.5 mg/kg/day. Inhaled and topical steroids are allowed.)
boolean
C0021081 (UMLS CUI [1])
C0279021 (UMLS CUI [2])
Concomitant Agent, Vaccination
Item
Planned administration/ administration of a vaccine not foreseen by the study protocol within 30 days of the first dose of vaccine(s).
boolean
C2347852 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
Vaccination, Previous
Item
Previous vaccination against Neisseria meningitidis, Haemophilus influenzae type b, diphtheria, tetanus, pertussis, poliovirus, and/or Streptococcus pneumoniae; more than one previous dose of hepatitis B vaccine. Vaccination with hepatitis B at birth is accepted (although not mandatory). Influenza (Flu) vaccination is allowed 30 days after the administration of the 3rd vaccine dose to 30 days preceding the booster dose.
boolean
C0042196 (UMLS CUI [1,1])
C0205156 (UMLS CUI [1,2])
Neisseria meningitidis, Medical History; Haemophilus influenzae type b, Medical History; Diphtheria, Medical History; Tetanus, Medical History; Pertussis, Medical History; Hepatitis B, Medical History; Human poliovirus, Medical History; Streptococcus pneumoniae, Medical History; Varicella zoster, Medical History
Item
History of Neisseria meningitidis, Haemophilus influenzae type b, diphtheria, tetanus, pertussis, hepatitis B, poliovirus, Streptococcus pneumoniae and/or varicella invasive disease.
boolean
C0027575 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
C0121772 (UMLS CUI [2,1])
C0262926 (UMLS CUI [2,2])
C0012546 (UMLS CUI [3,1])
C0262926 (UMLS CUI [3,2])
C0039614 (UMLS CUI [4,1])
C0262926 (UMLS CUI [4,2])
C0043167 (UMLS CUI [5,1])
C0262926 (UMLS CUI [5,2])
C0019163 (UMLS CUI [6,1])
C0262926 (UMLS CUI [6,2])
C0206435 (UMLS CUI [7,1])
C0262926 (UMLS CUI [7,2])
C0038410 (UMLS CUI [8,1])
C0262926 (UMLS CUI [8,2])
C0740380 (UMLS CUI [9,1])
C0262926 (UMLS CUI [9,2])
Immunosuppression; Immunologic Deficiency Syndromes
Item
Any confirmed or suspected immunosuppressive or immunodeficient condition, based on medical history and physical examination (no laboratory testing is required).
boolean
C4048329 (UMLS CUI [1])
C0021051 (UMLS CUI [2])
Hypersensitivity, Medical History
Item
History of allergic disease or reactions likely to be exacerbated by any component of the vaccine(s), including dry natural latex rubber, tetanus toxoid, diphtheria toxoid, neomycin, polymyxin.
boolean
C0020517 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
Congenital Abnormality, Major; Chronic disease, Serious
Item
Major congenital defects or serious chronic illness.
boolean
C0000768 (UMLS CUI [1,1])
C0205164 (UMLS CUI [1,2])
C0008679 (UMLS CUI [2,1])
C0205404 (UMLS CUI [2,2])
Nervous System Disorder, Medical History; Seizure, Medical History
Item
History of any neurologic disorders or seizures.
boolean
C0027765 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
C0036572 (UMLS CUI [2,1])
C0262926 (UMLS CUI [2,2])
Acute Disease
Item
Acute disease at the time of enrolment. (Acute disease is defined as the presence of a moderate or severe illness with or without fever. All vaccines can be administered to persons with a minor illness such as diarrhoea, mild upper respiratory infection with or without low-grade febrile illness, i.e. rectal temperature <38°C, axillary <37.5°C. A temperature greater than or equal to these cut-offs warrants deferral of the vaccination pending recovery of the subject).
boolean
C0001314 (UMLS CUI [1])
Immunoglobulins; Blood Product
Item
Administration of immunoglobulins and/or any blood products since birth or planned administration during the study period.
text
C0021027 (UMLS CUI [1,1])
C0371802 (UMLS CUI [1,2])
Randomization, Identifier
Item
Record treatment number
integer
C0034656 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Medical History
Item
Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study ?
boolean
C0262926 (UMLS CUI [1])
Physical Examination, Skin, Diagnosis
Item
Cutaneous - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C1123023 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Cutaneous
text
C0031809 (UMLS CUI [1,1])
C1123023 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Item
Eyes - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0015392 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Code List
Eyes - Diagnosis
Item
Eyes
text
C0031809 (UMLS CUI [1,1])
C0015392 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination, ENT examination, Diagnosis
Item
Ears-Nose-Throat - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0278350 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Ears-Nose-Throat
text
C0031809 (UMLS CUI [1,1])
C0278350 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Code List
Ears-Nose-Throat
Physical Examination, Cardiovascular system, Diagnosis
Item
Cardiovascular - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0007226 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Cardiovascular
text
C0031809 (UMLS CUI [1,1])
C0007226 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination, Respiratory system, Diagnosis
Item
Respiratory - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0035237 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Respiratory
text
C0031809 (UMLS CUI [1,1])
C0035237 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination, Gastrointestinal system, Diagnosis
Item
Gastrointestinal - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0012240 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Gastrointestinal
text
C0031809 (UMLS CUI [1,1])
C0012240 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Code List
Gastrointestinal
Physical Examination, Muskuloskeletal system, Diagnosis
Item
Muskuloskeletal - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0026860 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Muskuloskeletal
text
C0031809 (UMLS CUI [1,1])
C0026860 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Code List
Muskuloskeletal
Physical Examination, Neurologic Examination, Diagnosis
Item
Neurological - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0027853 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Neurological
text
C0031809 (UMLS CUI [1,1])
C0027853 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination, Genitourinary assessment, Diagnosis
Item
Genitourinary - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C1828035 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Genitourinary
text
C0031809 (UMLS CUI [1,1])
C1828035 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination, Hematology finding, Diagnosis
Item
Haematology - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0474523 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Haematology
text
C0031809 (UMLS CUI [1,1])
C0474523 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination, Hypersensitivity, Diagnosis
Item
Allergies - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0020517 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Allergies
text
C0031809 (UMLS CUI [1,1])
C0020517 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination,Endocrine system, Diagnosis
Item
Endocrine - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0014136 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Endocrine
text
C0031809 (UMLS CUI [1,1])
C0014136 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Physical Examination, Other, Diagnosis
Item
Other (specify) - Diagnosis
text
C0031809 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Other (specify)
text
C0031809 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C1444635 (UMLS CUI [1,3])
Code List
Other (specify)
Item
Has any vaccine been administered since birth ?
text
C0042210 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
Code List
Has any vaccine been administered since birth ?
CL Item
Yes, if yes, please complete the following table (3)
Vaccine, Medication name
Item
Trade / Generic Name
text
C0042210 (UMLS CUI [1,1])
C2360065 (UMLS CUI [1,2])
Vaccine, Dose Number
Item
Dose Number
integer
C0042210 (UMLS CUI [1,1])
C1115464 (UMLS CUI [1,2])
Administration of vaccine, Date in tine
Item
Estimated date of vaccine
date
C2368628 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Administration of vaccine, Date in time
Item
Date (fill in only if different from visit date)
date
C2368628 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Body Temperature, Vaccination, Before
Item
Pre-Vaccination temperature
float
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
Item
Route
text
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
C0449444 (UMLS CUI [1,4])
CL Item
Axillary (preferably) (1)
CL Item
Tympanic (oral conversion) (3)
CL Item
Tympanic (rectal conversion) (4)
Item
Vaccine Administration (only one box must be ticked by vaccine)
text
C2368628 (UMLS CUI [1])
Code List
Vaccine Administration (only one box must be ticked by vaccine)
CL Item
Hib-MenCY-TT Vaccine (1)
CL Item
Replacement vial (2)
CL Item
Not administered (4)
CL Item
Infanrix® penta Vaccine (5)
CL Item
Replacement vial (6)
CL Item
Not administered (8)
CL Item
Prevenar® Vaccine (9)
CL Item
Replacement vial (10)
CL Item
Not administered (12)
Administration of vaccine, Vial Device, Replacement, Identifier
Item
Vaccine Administration - Replacement vial number
integer
C2368628 (UMLS CUI [1,1])
C0184301 (UMLS CUI [1,2])
C0559956 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,4])
Administration of vaccine, Vial Device, Wrong, Identifier
Item
Vaccine Administration - Wrong vial number
integer
C2368628 (UMLS CUI [1,1])
C0184301 (UMLS CUI [1,2])
C3827420 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,4])
Item
Side / site route
text
C2368628 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
C0441987 (UMLS CUI [1,3])
C1515974 (UMLS CUI [1,4])
Code List
Side / site route
CL Item
Upper Right Thigh, I.M. (1)
CL Item
Upper Left Thigh, I.M. (2)
CL Item
Lower Left Thigh, I.M. (3)
Administration of vaccine, Protocol Compliance
Item
Has the study vaccine been administered according to the Protocol ?
boolean
C2368628 (UMLS CUI [1,1])
C0525058 (UMLS CUI [1,2])
Item
If No, Side
text
C2368628 (UMLS CUI [1,1])
C0441987 (UMLS CUI [1,2])
Item
If No, Site
text
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
Item
If No, Route
text
C2368628 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
Administration of vaccine, Comment
Item
Comments
text
C2368628 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Administration of vaccine, Date in time
Item
Date (fill in only if different from visit date)
date
C2368628 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Body Temperature, Vaccination, Before
Item
Pre-Vaccination temperature
float
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
Item
Route
text
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
C0449444 (UMLS CUI [1,4])
CL Item
Axillary (preferably) (1)
CL Item
Tympanic (oral conversion) (3)
CL Item
Tympanic (rectal conversion) (4)
Item
Vaccine Administration (only one box must be ticked by vaccine)
text
C2368628 (UMLS CUI [1])
Code List
Vaccine Administration (only one box must be ticked by vaccine)
CL Item
ActHIB® Vaccine (1)
CL Item
Replacement vial (2)
CL Item
Not administered (4)
CL Item
Infanrix® penta Vaccine (5)
CL Item
Replacement vial (6)
CL Item
Not administered (8)
CL Item
Prevenar® Vaccine (9)
CL Item
Replacement vial (10)
CL Item
Not administered (12)
CL Item
Meningitec® Vaccine (13)
CL Item
Replacement vial (14)
CL Item
Not administered (16)
Administration of vaccine, Vial Device, Replacement, Identifier
Item
Vaccine Administration - Replacement vial number
integer
C2368628 (UMLS CUI [1,1])
C0184301 (UMLS CUI [1,2])
C0559956 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,4])
Administration of vaccine, Vial Device, Wrong, Identifier
Item
Vaccine Administration - Wrong vial number
integer
C2368628 (UMLS CUI [1,1])
C0184301 (UMLS CUI [1,2])
C3827420 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,4])
Item
Side / site route
text
C2368628 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
C0441987 (UMLS CUI [1,3])
C1515974 (UMLS CUI [1,4])
Code List
Side / site route
CL Item
Upper Right Thigh, I.M. (1)
CL Item
Upper Left Thigh, I.M. (2)
CL Item
Lower Right Thigh, I.M. (3)
CL Item
Lower Left Thigh, I.M. (4)
Administration of vaccine, Protocol Compliance
Item
Has the study vaccine been administered according to the Protocol ?
boolean
C2368628 (UMLS CUI [1,1])
C0525058 (UMLS CUI [1,2])
Item
If No, Side
text
C2368628 (UMLS CUI [1,1])
C0441987 (UMLS CUI [1,2])
Item
If No, Site
text
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
Item
If No, Route
text
C2368628 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
Administration of vaccine, Comment
Item
Comments
text
C2368628 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Administration of vaccine, Date in time
Item
Date (fill in only if different from visit date)
date
C2368628 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Body Temperature, Vaccination, Before
Item
Pre-Vaccination temperature
float
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
Item
Route
text
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
C0449444 (UMLS CUI [1,4])
CL Item
Axillary (preferably) (1)
CL Item
Tympanic (oral conversion) (3)
CL Item
Tympanic (rectal conversion) (4)
Item
Vaccine Administration (only one box must be ticked by vaccine)
text
C2368628 (UMLS CUI [1])
Code List
Vaccine Administration (only one box must be ticked by vaccine)
CL Item
ActHIB® Vaccine (1)
CL Item
Replacement vial (2)
CL Item
Not administered (4)
CL Item
Infanrix® penta Vaccine (5)
CL Item
Replacement vial (6)
CL Item
Not administered (8)
CL Item
Prevenar® Vaccine (9)
CL Item
Replacement vial (10)
CL Item
Not administered (12)
Administration of vaccine, Vial Device, Replacement, Identifier
Item
Vaccine Administration - Replacement vial number
integer
C2368628 (UMLS CUI [1,1])
C0184301 (UMLS CUI [1,2])
C0559956 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,4])
Administration of vaccine, Vial Device, Wrong, Identifier
Item
Vaccine Administration - Wrong vial number
integer
C2368628 (UMLS CUI [1,1])
C0184301 (UMLS CUI [1,2])
C3827420 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,4])
Item
Side / site route
text
C2368628 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
C0441987 (UMLS CUI [1,3])
C1515974 (UMLS CUI [1,4])
Code List
Side / site route
CL Item
Upper Right Thigh, I.M. (1)
CL Item
Upper Left Thigh, I.M. (2)
CL Item
Lower Left Thigh, I.M. (3)
Administration of vaccine, Protocol Compliance
Item
Has the study vaccine been administered according to the Protocol ?
boolean
C2368628 (UMLS CUI [1,1])
C0525058 (UMLS CUI [1,2])
Item
If No, Side
text
C2368628 (UMLS CUI [1,1])
C0441987 (UMLS CUI [1,2])
Item
If No, Site
text
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
Item
If No, Route
text
C2368628 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
Administration of vaccine, Comment
Item
Comments
text
C2368628 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Item
Why not administered? Please tick the ONE most appropriate category for non administration
text
C2368628 (UMLS CUI [1,1])
C2826287 (UMLS CUI [1,2])
Code List
Why not administered? Please tick the ONE most appropriate category for non administration
CL Item
Serious adverse event (Please specify SAE N°) (1)
CL Item
Non-Serious adverse event (Please specify unsolicited AE N° or solicited AE code) (2)
CL Item
Other, please specify (e.g. consent withdrawal, recoil violation, ...) (3)
Item
Why not administered? - Specifications
text
C2368628 (UMLS CUI [1,1])
C2826287 (UMLS CUI [1,2])
Code List
Why not administered? - Specifications
Item
Please tick who took the decision
text
C2368628 (UMLS CUI [1,1])
C1272696 (UMLS CUI [1,2])
C0679006 (UMLS CUI [1,3])
Code List
Please tick who took the decision
CL Item
Parents/Guardians (2)