Subject Identifier
Item
Subject Identifier
text
C2348585 (UMLS CUI [1])
Centre Number
Item
Centre Number
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Randomisation Number
Item
Randomisation Number
integer
C0034656 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Were any concomitant medications taken by the subject during the study?
Item
Were any concomitant medications taken by the subject during the study?
boolean
C2347852 (UMLS CUI [1])
Drug Name
Item
Drug Name
text
C0013227 (UMLS CUI [1])
Concomitant Medication Unit Dose
Item
Concomitant Medication Unit Dose
float
C0869039 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
Item
Concomitant Medication Units
text
C1519795 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
Code List
Concomitant Medication Units
Item
Concomitant Medications Frequency
text
C3476109 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
Code List
Concomitant Medications Frequency
CL Item
1 x Daily (OD/QD)
CL Item
As required (PRN)
Item
Concomitant Medication Route
text
C2826730 (UMLS CUI [1])
Code List
Concomitant Medication Route
CL Item
Intramuscular (IM)
Reason for Medication
Item
Reason for Medication
text
C2826696 (UMLS CUI [1])
Concomitant Medication Start Date
Item
Concomitant Medication Start Date
date
C2826734 (UMLS CUI [1])
Concomitant Medication Start Time
Item
Concomitant Medication Start Time
time
C1301880 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
Concomitant Medication taken prior to study?
Item
Concomitant Medication taken prior to study?
boolean
C2347852 (UMLS CUI [1,1])
C2603343 (UMLS CUI [1,2])
C1883727 (UMLS CUI [1,3])
C0332152 (UMLS CUI [1,4])
Concomitant Medication Stop Date
Item
Concomitant Medication Stop Date
date
C2826744 (UMLS CUI [1])
Concomitant Medication Stop Time
Item
Concomitant Medication Stop Time
time
C2347852 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
Ongoing Medication?
Item
Ongoing Medication?
boolean
C2826666 (UMLS CUI [1])
Did the subject experience any non-serious adverse events during the study?
Item
Did the subject experience any non-serious adverse events during the study?
boolean
C1518404 (UMLS CUI [1])
Event
Item
Event
text
C1518404 (UMLS CUI [1])
Non-Serious Adverse Event Start Date
Item
Non-Serious Adverse Event Start Date
date
C1518404 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Non-Serious Adverse Event Start Time
Item
Non-Serious Adverse Event Start Time
time
C1518404 (UMLS CUI [1,1])
C1301880 (UMLS CUI [1,2])
Item
Non-Serious Adverse Event Outcome
text
C1518404 (UMLS CUI [1,1])
C1705586 (UMLS CUI [1,2])
Code List
Non-Serious Adverse Event Outcome
CL Item
Recovered/Resolved (1)
CL Item
Recovering/Resolving (2)
CL Item
Not recovered/Not resolved (3)
CL Item
Recovered/Resolved with sequelae (4)
Non-Serious Adverse Event End Date
Item
Non-Serious Adverse Event End Date
date
C1518404 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Non-Serious Adverse Event End Time
Item
Non-Serious Adverse Event End Time
time
C1518404 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
Item
Non-Serious Adverse Event Frequency
integer
C1518404 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
Code List
Non-Serious Adverse Event Frequency
CL Item
Single episode (1)
Item
Non-Serious Adverse Event Maximum Intensity
text
C1519255 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
C0806909 (UMLS CUI [1,3])
Code List
Non-Serious Adverse Event Maximum Intensity
CL Item
Not applicable (X)
Item
Action Taken with investigational Product(s) as a Result of the Non-Serious AE
text
C1704758 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Code List
Action Taken with investigational Product(s) as a Result of the Non-Serious AE
CL Item
Investigational product(s) withdrawn (1)
CL Item
Dose increased (3)
CL Item
Dose not changed (4)
CL Item
Dose interrupted (5)
CL Item
Not applicable (X)
Did the subject withdraw from study as a result of this AE?
Item
Did the subject withdraw from study as a result of this AE?
boolean
C1710677 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
ls there a reasonable possibility that the AE may have been caused by the investigational product?
Item
ls there a reasonable possibility that the AE may have been caused by the investigational product?
boolean
C1518404 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Did the subject experience a serious adverse event during the study?
Item
Did the subject experience a serious adverse event during the study?
boolean
C1519255 (UMLS CUI [1])
Event
Item
Event
text
C1519255 (UMLS CUI [1])
Serious Adverse Event Start Date
Item
Serious Adverse Event Start Date
date
C1519255 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Serious Adverse Event Start Time
Item
Serious Adverse Event Start Time
time
C1519255 (UMLS CUI [1,1])
C1301880 (UMLS CUI [1,2])
Item
Serious Adverse Event Outcome
integer
C1705586 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Code List
Serious Adverse Event Outcome
CL Item
Recovered/Resolved (1)
CL Item
Recovering/Resolving (2)
CL Item
Not recovered/Not resolved (3)
CL Item
Recovered/Resolved with sequelae (4)
Serious Adverse Event End Date
Item
Serious Adverse Event End Date
date
C1519255 (UMLS CUI [1])
Item
Serious Adverse Event Maximum Intensity
text
C1519255 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
C0806909 (UMLS CUI [1,3])
Code List
Serious Adverse Event Maximum Intensity
CL Item
Not applicable (X)
Item
Action Taken with lnvestigational Product(s) as a Result of the SAE
text
C1704758 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Code List
Action Taken with lnvestigational Product(s) as a Result of the SAE
CL Item
lnvestigational product(s) withdrawn (1)
CL Item
Dose increased (3)
CL Item
Dose not changed (4)
CL Item
Dose interrupted (5)
CL Item
Not applicable (X)
Did the subject withdraw from study as a result of this SAE?
Item
Did the subject withdraw from study as a result of this SAE?
boolean
C2349954 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
ls there a reasonable possibility the SAE may have been caused by the investigational product?
Item
ls there a reasonable possibility the SAE may have been caused by the investigational product?
boolean
C1519255 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Item
Serious Adverse Event Seriousness
text
C1710056 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Code List
Serious Adverse Event Seriousness
CL Item
Results in death (A)
CL Item
ls life-threatening (B)
CL Item
Requires hospitalisation or prolongation of existing hospitalisation (C)
CL Item
Results in disability/incapacity (D)
CL Item
Congenital anomaly/birth defect (E)
CL Item
Other, specify (see definition of SAE) (F)
If other Sersiousness of SAE, specify.
Item
If other Sersiousness of SAE, specify.
text
C1710056 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
Item
If investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further lnvestigational Product(s) were Administered?
text
C1519255 (UMLS CUI [1,1])
C0034897 (UMLS CUI [1,2])
Code List
If investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further lnvestigational Product(s) were Administered?
CL Item
Unknown at this time (3)
CL Item
Not applicable (4)
Item
Possible Causes of SAE Other Than investigational Product(s)
integer
C1519255 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C0304229 (UMLS CUI [2,1])
C0205394 (UMLS CUI [2,2])
Code List
Possible Causes of SAE Other Than investigational Product(s)
CL Item
Disease under study (1)
CL Item
Medical condition(s) specify (2)
CL Item
Lack of efficacy (3)
CL Item
Withdrawal of investigational product(s) (4)
CL Item
Concomitant medication(s) specify (5)
CL Item
Activity related to study participation (e.g., procedures) (6)
CL Item
Other, specify (7)
Medical conditions(s) specification
Item
Medical conditions(s) specification
text
C0012634 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Concomitant medication(s) specification
Item
Concomitant medication(s) specification
text
C2347852 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Specification of other reason
Item
Specification of other reason
text
C3840932 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Specify any RELEVANT past or current medical disorders, allergies, surgeries, etc. that can help explain the SAE
Item
Specify any RELEVANT past or current medical disorders, allergies, surgeries, etc. that can help explain the SAE
text
C0012634 (UMLS CUI [1,1])
C2347946 (UMLS CUI [1,2])
C0020517 (UMLS CUI [2,1])
C2347946 (UMLS CUI [2,2])
C0543467 (UMLS CUI [3,1])
C2347946 (UMLS CUI [3,2])
C1519255 (UMLS CUI [4,1])
C0681841 (UMLS CUI [4,2])
Medical Condition Date of Onset
Item
Medical Condition Date of Onset
date
C0012634 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
Condition Present at Time of the SAE?
Item
Condition Present at Time of the SAE?
boolean
C0012634 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
If not present at time of the SAE, Date of Last Occurrence
Item
If not present at time of the SAE, Date of Last Occurrence
date
C2745955 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Other RELEVANT Risk Factors
Item
Other RELEVANT Risk Factors (provide any family or social history (e.g., smoking, alcohol, diet, drug abuse, occupational hazard) relevant to the SAE
text
C0035648 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C2347946 (UMLS CUI [1,4])
C3714536 (UMLS CUI [2,1])
C0241889 (UMLS CUI [2,2])
C0543414 (UMLS CUI [3])
C0001948 (UMLS CUI [4])
C0012155 (UMLS CUI [5])
C0013146 (UMLS CUI [6])
C0337074 (UMLS CUI [7])
Serious Adverse Event - Concomitant Medication Drug Name
Item
Serious Adverse Event - Concomitant Medication Drug Name
text
C0013227 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
C2347852 (UMLS CUI [1,3])
Serious Adverse Event - Concomitant Medication Dose
Item
Serious Adverse Event - Concomitant Medication Dose
float
C1519255 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
C3174092 (UMLS CUI [1,3])
Serious Adverse Event - Concomitant Medication Unit
Item
Serious Adverse Event - Concomitant Medication Unit
text
C1519255 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
C1519795 (UMLS CUI [1,3])
Serious Adverse Event - Concomitant Medication Frequency
Item
Serious Adverse Event - Concomitant Medication Frequency
text
C1519255 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
C3476109 (UMLS CUI [1,3])
Serious Adverse Event - Concomitant Medication Route
Item
Serious Adverse Event - Concomitant Medication Route
text
C1519255 (UMLS CUI [1,1])
C2826730 (UMLS CUI [1,2])
Serious Adverse Event - Concomitant Medication Taken prior to study?
Item
Serious Adverse Event - Concomitant Medication Taken prior to study?
boolean
C1519255 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
C2603343 (UMLS CUI [1,3])
C1883727 (UMLS CUI [1,4])
C0332152 (UMLS CUI [1,5])
Serious Adverse Event - Concomitant Medication Start Date
Item
Serious Adverse Event - Concomitant Medication Start Date
date
C1519255 (UMLS CUI [1,1])
C2826734 (UMLS CUI [1,2])
Serious Adverse Event - Concomitant Medication Stop Date
Item
Serious Adverse Event - Concomitant Medication Stop Date
date
C1519255 (UMLS CUI [1,1])
C2826744 (UMLS CUI [1,2])
Serious Adverse Event - Concomitant Medication Ongoing?
Item
Serious Adverse Event - Concomitant Medication Ongoing?
boolean
C1519255 (UMLS CUI [1,1])
C2826666 (UMLS CUI [1,2])
Serious Adverse Event Reason - for Concomitant Medication
Item
Serious Adverse Event - Reason for Concomitant Medication
text
C1519255 (UMLS CUI [1,1])
C2826696 (UMLS CUI [1,2])
Details of investigational Product(s)
Item
Details of investigational Product(s)
text
C0304229 (UMLS CUI [1,1])
C1522508 (UMLS CUI [1,2])
Item
Was treatment blind broken at investigational site?
integer
C3897431 (UMLS CUI [1])
Code List
Was treatment blind broken at investigational site?
CL Item
Not applicable (3)
Details of RELEVANT Assessments
Item
Details of RELEVANT Assessments
text
C1261322 (UMLS CUI [1,1])
C1522508 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,3])
Narrative Remarks
Item
Narrative Remarks
text
C0947611 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
lnvestigator's signature
Item
lnvestigator's signature
text
C2346576 (UMLS CUI [1])
lnvestigator's name (print)
Item
lnvestigator's name (print)
text
C2826892 (UMLS CUI [1])
Signature Date
Item
Signature Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])