ID

36907

Beschreibung

Study ID: 101468/201 Clinical Study ID: 101468/201 Study Title: A Single Blind, Parallel Group, Up-titration, Phase 1 Study in Healthy Volunteers to Determine a Starting Dose and Select an Up-titration Regimen for a new Formulation of Ropinirole Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 1 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Modutab,ZIPEREVE,ZEPREVE,REPREVE,ADARTREL,REQUIP,Zygara; Zygara,ZIPEREVE,ZEPREVE,Requip Depot,REQUIP,REPREVE,Modutab,ADARTREL Study Indication : Restless Legs Syndrome The Study consists of 21 Visits(Days): Screening (at least 21 days before dosing) Week 1: including Day 1-7 Week 2: including Day 8-14 Week 3: including Day 15-19 Follow-up Visit (7-14 days after last dose) This document contains the Pre-dose Drug screen, Pre-dose pregnancy test and the pre-dose alcohol test form. It has to be filled in at Day 1.

Stichworte

Versionen (2)
  1. 01.09.17 01.09.17 -
  2. 21.06.19 21.06.19 -
Rechteinhaber

GlaxoSmithKline

Hochgeladen am

21. Juni 2019

DOI

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Creative Commons BY-NC 3.0
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Determination of starting dose and up-titration regimen for a new formulation of Ropinirole in healthy adults, 101468/201

Englisch

Pre- Dose Drug Screening, Pregnancy test, Alcohol test

1 Formulare  
Administrative Data
Beschreibung

Administrative Data

Alias
UMLS CUI-1
C1320722
Subject number
Beschreibung

Subject number

Datentyp

integer

Alias
UMLS CUI [1]
C2348585
Pre-dose Drug Screening (Urine)
Beschreibung

Pre-dose Drug Screening (Urine)

Alias
UMLS CUI-1
C0202274
Date of test
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1]
C2826247
Time of test
Beschreibung

00:00-23:59

Datentyp

time

Alias
UMLS CUI [1]
C0429928
Were there any contra-indicated drugs detected?
Beschreibung

If you tick ‘Yes’, please record all the relevant contra-indicated drugs below. If positive please withdraw the subject from the study.

Datentyp

text

Alias
UMLS CUI [1,1]
C1301624
UMLS CUI [1,2]
C0013227
If there are contraindicateddrugs, please specify type of Drug
Beschreibung

Type of Drug

Datentyp

text

Alias
UMLS CUI [1]
C0457591
Comment
Beschreibung

Comment

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Pre-dose Alcohol test
Beschreibung

Pre-dose Alcohol test

Alias
UMLS CUI-1
C0202304
Date of test
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1]
C2826247
Time of test
Beschreibung

00:00-23:59

Datentyp

time

Alias
UMLS CUI [1]
C0429928
Alcohol test finding
Beschreibung

If positive please withdraw the subject from the study.

Datentyp

text

Alias
UMLS CUI [1]
C0495718
Pre-dose Pregnancy test
Beschreibung

Pre-dose Pregnancy test

Alias
UMLS CUI-1
C0032976
Was a pregnancy test carried out?
Beschreibung

Test performance

Datentyp

text

Alias
UMLS CUI [1,1]
C1518965
UMLS CUI [1,2]
C0032976
If test was not performed, please specify reason
Beschreibung

Test not performed, reason

Datentyp

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C3841220
UMLS CUI [1,3]
C0032976
If test wasperformed, please specify Date of test
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1]
C2826247
If test wasperformed, please specify Time of test
Beschreibung

00:00-23:59

Datentyp

time

Alias
UMLS CUI [1]
C0429928
Test result
Beschreibung

If ‘Positive’, withdraw subject from the study

Datentyp

text

Alias
UMLS CUI [1]
C0427777
Test type
Beschreibung

Pregnancy test type

Datentyp

integer

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0332307
If other test type, pease specify
Beschreibung

Other Pregnancy test type

Datentyp

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0032976
UMLS CUI [1,3]
C0332307
Laboratory name, if applicable
Beschreibung

Ensure result is included on laboratory report

Datentyp

text

Alias
UMLS CUI [1]
C3258037
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Ähnliche Modelle

Pre- Dose Drug Screening, Pregnancy test, Alcohol test

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Subject number
Item
Subject number
integer
C2348585 (UMLS CUI [1])
Item Group
Pre-dose Drug Screening (Urine)
C0202274 (UMLS CUI-1)
Date of test
Item
Date of test
date
C2826247 (UMLS CUI [1])
Time of test
Item
Time of test
time
C0429928 (UMLS CUI [1])
Item
Were there any contra-indicated drugs detected?
text
C1301624 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Contraindication drugs
Code List
Were there any contra-indicated drugs detected?
CL Item
Yes (Y)
CL Item
No (N)
Type of Drug
Item
If there are contraindicateddrugs, please specify type of Drug
text
C0457591 (UMLS CUI [1])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Item Group
Pre-dose Alcohol test
C0202304 (UMLS CUI-1)
Date of test
Item
Date of test
date
C2826247 (UMLS CUI [1])
Time of test
Item
Time of test
time
C0429928 (UMLS CUI [1])
Item
Alcohol test finding
text
C0495718 (UMLS CUI [1])
Alcohol test finding
Code List
Alcohol test finding
CL Item
Positive (P)
CL Item
Negative (N)
Item Group
Pre-dose Pregnancy test
C0032976 (UMLS CUI-1)
Item
Was a pregnancy test carried out?
text
C1518965 (UMLS CUI [1,1])
C0032976 (UMLS CUI [1,2])
Test performance
Code List
Was a pregnancy test carried out?
CL Item
Yes (Y)
CL Item
No (N)
Item
If test was not performed, please specify reason
text
C0566251 (UMLS CUI [1,1])
C3841220 (UMLS CUI [1,2])
C0032976 (UMLS CUI [1,3])
Test performance
Code List
If test was not performed, please specify reason
Date of test
Item
If test wasperformed, please specify Date of test
date
C2826247 (UMLS CUI [1])
Time of test
Item
If test wasperformed, please specify Time of test
time
C0429928 (UMLS CUI [1])
Item
Test result
text
C0427777 (UMLS CUI [1])
Test result
Code List
Test result
CL Item
Positive (P)
CL Item
Negative (N)
Item
Test type
integer
C0032976 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Pregnancy test type
Code List
Test type
CL Item
Dipstick urine HCG (1)
CL Item
Serum HCG (2)
CL Item
Other (3)
Other Pregnancy test type
Item
If other test type, pease specify
text
C0205394 (UMLS CUI [1,1])
C0032976 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
Laboratory name
Item
Laboratory name, if applicable
text
C3258037 (UMLS CUI [1])
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