Clinical Trials, Withdraw
Item
Did the patient prematurely terminate the study or was she prematurely withdrawn?
boolean
C0008976 (UMLS CUI [1,1])
C2349954 (UMLS CUI [1,2])
Clinical Trials, Withdraw, Date in time
Item
If "yes", please document the date
date
C0008976 (UMLS CUI [1,1])
C2349954 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
If "yes", please provide the primary reason for withdrawal
text
C0008976 (UMLS CUI [1,1])
C2349954 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
Code List
If "yes", please provide the primary reason for withdrawal
CL Item
Adverse event (1)
CL Item
Insufficient therapeutic effect (2)
CL Item
Protocol violation (incl. non-compliance) (3)
CL Item
Patient is lost to follow-up (4)
CL Item
Other, please specify (5)
Clinical Trials, Withdraw, Reason and justification
Item
Please specify
text
C0008976 (UMLS CUI [1,1])
C2349954 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
Investigator Signature
Item
Signature of the responsible investigator I hereby declare that the data documented in his case report form are an exact and correct repetition of the patient's findings, that the trial was conducted according to protocol, and that the patient's consent for the study participation has been obtained.
text
C2346576 (UMLS CUI [1])
Investigator Signature, Date in time
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator Name
Item
Name in printed letters or practice stamp
text
C2826892 (UMLS CUI [1])