Type of Report
Randomisation
Serious adverse event Entry
Hidden
text
SAE Diagnosis or Sign/Symptom
text
Hidden
text
Hidden
text
Hidden
text
Hidden
boolean
Adverse Event Start Date/Time
datetime
if Recovered/Resolved (with or without sequelae) provide End Date and Time if Fatal, record Date and Time of Death
integer
if applicable
datetime
Serious Adverse Event Frequency
integer
SAE Maximum Intensity
text
[hidden]
text
[hidden]
text
Action regarding Investigational Product
text
subject withdrawal because of AE
boolean
AE possibly caused by investigational product
boolean
[hidden]
time
[hidden]
time
SAE caused by activities related to study participation
boolean
[hidden]
boolean
Seriousness
Adverse Event Results in death
boolean
Adverse event is life-threatening
boolean
adverse event requires hospitalisation or prolongation of hospitalisation
boolean
Serious adverse event results in disability/incapacity
boolean
Serious adverse event: Congenital anomaly/birth defect
boolean
specify within general narrative comment
boolean
ALT >= 5xULN and bilirubin >= 2xULN (>35% direct).
boolean
Relevant concomitant/treatment medications Entry
[hidden]
text
(Trade Name preferred)
text
Dose
text
Unit of concomitant medication
text
Concomitant medication Frequency
text
Route of concomitant medication
text
Concomitant Medication Start Date
date
if no, specify End Date
boolean
Concomitant medication end date
date
Concomitant Medication Primary Indication
text
Drug Type
text
Relevant Medical Conditions/Risk Factors
[hidden]
text
Specific Condition
text
Date of onset
date
If no, specify date of last occurrence
text
Date of last disease occurence
date
Relevant Other Medical History / Risk Factors
text
Relevant Diagnostic Results
[hidden]
text
Lab Test Name
text
Test Date
date
Laboratory Test Result
text
Laboratory Test Units
text
Normal Low Range
text
Normal High Range
text
Relevant other diagnostic laboratory results
text
Investigational Product
event recurence after investigational product administered again
text
General narrative comments
Non clinical
[hidden]
boolean
[hidden]
datetime
[hidden]
boolean
[hidden]
text
[hidden]
text
[hidden]
text
[hidden]
text
[hidden]
text
[hidden]
text