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])
Serious Adverse Event, During, Clinical Trials
Item
Has the subject had any SAEs since the end of the primary phase and before the start of this booster study ?
boolean
C1519255 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
Serious Adverse Event, During, Clinical Trials, Numbers
Item
If Yes, Specify number of SAEs
integer
C1519255 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
C0237753 (UMLS CUI [1,4])
Adverse Event, During, Clinical Trials
Item
Has the subject had any specific AEs include onset of chronic illness(es) (e.g. autoimmune disorders, asthma, type I diabetes and allergies), rash (hives, idiopathic thrombocytopenic purpura, petechiae), since the end of the primary phase and before the start of this booster study ?
boolean
C0877248 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
Adverse Event, During, Clinical Trials, Numbers
Item
If Yes, Specify number of specific AEs
boolean
C0877248 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
C0237753 (UMLS CUI [1,4])
Eligibility Determination
Item
Did the subject meet all the entry criteria ?
boolean
C0013893 (UMLS CUI [1])
Measles, Medical History; Mumps, Medical History; Rubella, Medical History; Varicella zoster, Medical History
Item
History of measles, mumps, rubella or varicella.
boolean
C0025007 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
C0026780 (UMLS CUI [2,1])
C0262926 (UMLS CUI [2,2])
C0035920 (UMLS CUI [3,1])
C0262926 (UMLS CUI [3,2])
C0740380 (UMLS CUI [4,1])
C0262926 (UMLS CUI [4,2])
Measles, Vaccination, Previous; Mumps, Vaccination, Previous; Rubella, Vaccination, Previous; Varicella zoster, Vaccination, Previous
Item
Previous vaccination against measles, mumps, rubella or varicella.
boolean
C0025007 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0205156 (UMLS CUI [1,3])
C0026780 (UMLS CUI [2,1])
C0042196 (UMLS CUI [2,2])
C0205156 (UMLS CUI [2,3])
C0035920 (UMLS CUI [3,1])
C0042196 (UMLS CUI [3,2])
C0205156 (UMLS CUI [3,3])
C0740380 (UMLS CUI [4,1])
C0042196 (UMLS CUI [4,2])
C0205156 (UMLS CUI [4,3])
Haemophilus influenzae type b polysaccharide vaccine, Previous; Meningococcal group C vaccine, Previous
Item
Previous booster vaccination with Hib or meningococcal serogroup C vaccine since the last visit of the primary phase.
boolean
C0062086 (UMLS CUI [1,1])
C0205156 (UMLS CUI [1,2])
C1720015 (UMLS CUI [2,1])
C0205156 (UMLS CUI [2,2])
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])
Item
Has any relevant medication been administered since the last visit of the primary phase of the study ?
text
C0013227 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
Code List
Has any relevant medication been administered since the last visit of the primary phase of the study ?
Pharmaceutical Preparations, Medication name
Item
Trade / Generic Name
text
C0013227 (UMLS CUI [1,1])
C2360065 (UMLS CUI [1,2])
Pharmaceutical Preparations, Indication
Item
Medical Indication
text
C0013227 (UMLS CUI [1,1])
C3146298 (UMLS CUI [1,2])
Pharmaceutical Preparations, Daily Dose, Total
Item
Total daily dose
text
C0013227 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
C0439810 (UMLS CUI [1,3])
Pharmaceutical Preparations, Drug Administration Routes
Item
Route
text
C0013227 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
Pharmaceutical Preparations, Start Date
Item
Start Date
date
C0013227 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Pharmaceutical Preparations, End Date
Item
End Date
date
C0013227 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Pharmaceutical Preparations, Continuous
Item
Tick box if continuing at end of study
boolean
C0013227 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Collection of blood specimen for laboratory procedure
Item
Has a blood sample been taken ?
boolean
C0005834 (UMLS CUI [1])
Collection of blood specimen for laboratory procedure, Date in time
Item
Please complete only if different from visit date
date
C0005834 (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
M-M-R® II Vaccine (5)
CL Item
Replacement vial (6)
CL Item
Not administered (8)
CL Item
Varivax® 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 Right Arm, S.C. (2)
CL Item
Upper Left Arm, S.C. (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
PedvaxHIB® Vaccine (1)
CL Item
Replacement vial (2)
CL Item
Not administered (4)
CL Item
M-M-R® II Vaccine (5)
CL Item
Replacement vial (6)
CL Item
Not administered (8)
CL Item
Varivax® 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 Right Arm, S.C. (2)
CL Item
Upper Left Arm, S.C. (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)