Inglês

Study Continuation, Screen Failure, Investigator Signature

1 Formulários  
Administrative Data
Descrição

Administrative Data

Alias
UMLS CUI-1
C1320722
Date of Visit/Assessment
Descrição

Date of Visit/Assessment

Tipo de dados

date

Alias
UMLS CUI [1]
C1320303
UMLS CUI [2]
C2985720
Site
Descrição

Study site

Tipo de dados

text

Alias
UMLS CUI [1]
C2825164
Patient
Descrição

Patient

Tipo de dados

text

Alias
UMLS CUI [1]
C1299487
Patient No.
Descrição

Subject No.

Tipo de dados

text

Alias
UMLS CUI [1]
C2348585
Type of Visit
Descrição

At Visit 1 (Screening) and 2, fill in all three itemgroups. At Visit 3, fill in "Screen Failure" and "Investigator Signature" only.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C0332307
Prompt
Descrição

Prompt

Alias
UMLS CUI-1
C0805733
UMLS CUI-2
C0008976
Will the subject continue to the next visit?
Descrição

Applicable to Visit 1 and 2 only

Tipo de dados

boolean

Alias
UMLS CUI [1,1]
C0805733
UMLS CUI [1,2]
C0008976
Screen Failure
Descrição

Screen Failure

Alias
UMLS CUI-1
C1710476
Was this subject a screen failure?
Descrição

If yes, record date and check all reasons that apply.

Tipo de dados

boolean

Alias
UMLS CUI [1]
C1710476
Screen Failure Date
Descrição

Screen Failure Date

Tipo de dados

date

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C0011008
Did not meet inclusion/exclusion criteria
Descrição

Reason for Screening Failure: Inclusion/Exclusion Criteria

Tipo de dados

boolean

Alias
UMLS CUI [1,1]
C1512693
UMLS CUI [1,2]
C0231175
UMLS CUI [2,1]
C0680251
UMLS CUI [2,2]
C0231175
UMLS CUI [3,1]
C0566251
UMLS CUI [3,2]
C1710476
Investigator Discretion
Descrição

Specify in next item

Tipo de dados

boolean

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C1710476
UMLS CUI [2,1]
C0008961
UMLS CUI [2,2]
C0022423
Investigator Discretion, specify
Descrição

Reason for Screening Failure: Specify investigator Discretion

Tipo de dados

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C1710476
UMLS CUI [2,1]
C0008961
UMLS CUI [2,2]
C0022423
UMLS CUI [2,3]
C1521902
Failed PSG inclusion criteria on Central PSG judgement
Descrição

Reason for Screening Failure: Failed Polysomnography inclusion criteria on sponsor judgement

Tipo de dados

boolean

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C1710476
UMLS CUI [2,1]
C0162701
UMLS CUI [2,2]
C1512693
UMLS CUI [2,3]
C0231175
UMLS CUI [2,4]
C2347796
UMLS CUI [2,5]
C0022423
Failed PSG inclusion criteria on Investigator judgement
Descrição

Reason for Screening Failure: Failed Polysomnography inclusion criteria on Investigator judgement

Tipo de dados

boolean

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C1710476
UMLS CUI [2,1]
C0162701
UMLS CUI [2,2]
C1512693
UMLS CUI [2,3]
C0231175
UMLS CUI [2,4]
C0008961
UMLS CUI [2,5]
C0022423
For Data Managers or Monitors only: Require the investigator to re-sign the case book
Descrição

By ticking or unticking this box you are evoking a change to this form that will invalidate the original signature and will revert the form back to an unsigned state. This should be done when significant changes (e.g. those that require medical opinion or other significant situations) occur after the original signature. If the box is already ticked upon arrival on this form, unticking and submitting it accomplishes the same task as licking and submitting if; that is, the signature will be invalidated in both instances.

Tipo de dados

boolean

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0205341
UMLS CUI [1,3]
C1514873
Investigator Signature
Descrição

Investigator Signature

Alias
UMLS CUI-1
C2346576
Is this casebook ready to sign?
Descrição

Only select if casebook is ready to sign/finished. Original comment: "If not, click on the RETURN button below"

Tipo de dados

boolean

Alias
UMLS CUI [1]
C2346576
For Data Managers or Monitors only: Require the investigator to re-sign the case book
Descrição

By ticking or unticking this box you are evoking a change to this form that will invalidate the original signature and will revert the form back to an unsigned state. This should be done when significant changes (e.g. those that require medical opinion or other significant situations) occur after the original signature. If the box is already ticked upon arrival on this form, unticking and submitting it accomplishes the same task as licking and submitting if; that is, the signature will be invalidated in both instances.

Tipo de dados

boolean

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0205341
UMLS CUI [1,3]
C1514873
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Similar models

Study Continuation, Screen Failure, Investigator Signature

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Date of Visit/Assessment
Item
Date of Visit/Assessment
date
C1320303 (UMLS CUI [1])
C2985720 (UMLS CUI [2])
Study site
Item
Site
text
C2825164 (UMLS CUI [1])
Patient
Item
Patient
text
C1299487 (UMLS CUI [1])
Subject No.
Item
Patient No.
text
C2348585 (UMLS CUI [1])
Item
Type of Visit
text
C0545082 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Visit Type
Code List
Type of Visit
CL Item
Visit 1 (Screening) (Visit 1 (Screening))
CL Item
Visit 2 (Visit 2)
CL Item
Visit 3 (Visit 3)
Item Group
Prompt
C0805733 (UMLS CUI-1)
C0008976 (UMLS CUI-2)
Study Continuation
Item
Will the subject continue to the next visit?
boolean
C0805733 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
Item Group
Screen Failure
C1710476 (UMLS CUI-1)
Screen Failure
Item
Was this subject a screen failure?
boolean
C1710476 (UMLS CUI [1])
Screen Failure Date
Item
Screen Failure Date
date
C1710476 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Reason for Screening Failure: Inclusion/Exclusion Criteria
Item
Did not meet inclusion/exclusion criteria
boolean
C1512693 (UMLS CUI [1,1])
C0231175 (UMLS CUI [1,2])
C0680251 (UMLS CUI [2,1])
C0231175 (UMLS CUI [2,2])
C0566251 (UMLS CUI [3,1])
C1710476 (UMLS CUI [3,2])
Reason for Screening Failure: Investigator Discretion
Item
Investigator Discretion
boolean
C0566251 (UMLS CUI [1,1])
C1710476 (UMLS CUI [1,2])
C0008961 (UMLS CUI [2,1])
C0022423 (UMLS CUI [2,2])
Reason for Screening Failure: Specify investigator Discretion
Item
Investigator Discretion, specify
text
C0566251 (UMLS CUI [1,1])
C1710476 (UMLS CUI [1,2])
C0008961 (UMLS CUI [2,1])
C0022423 (UMLS CUI [2,2])
C1521902 (UMLS CUI [2,3])
Reason for Screening Failure: Failed Polysomnography inclusion criteria on sponsor judgement
Item
Failed PSG inclusion criteria on Central PSG judgement
boolean
C0566251 (UMLS CUI [1,1])
C1710476 (UMLS CUI [1,2])
C0162701 (UMLS CUI [2,1])
C1512693 (UMLS CUI [2,2])
C0231175 (UMLS CUI [2,3])
C2347796 (UMLS CUI [2,4])
C0022423 (UMLS CUI [2,5])
Reason for Screening Failure: Failed Polysomnography inclusion criteria on Investigator judgement
Item
Failed PSG inclusion criteria on Investigator judgement
boolean
C0566251 (UMLS CUI [1,1])
C1710476 (UMLS CUI [1,2])
C0162701 (UMLS CUI [2,1])
C1512693 (UMLS CUI [2,2])
C0231175 (UMLS CUI [2,3])
C0008961 (UMLS CUI [2,4])
C0022423 (UMLS CUI [2,5])
Investigator Re-Sign required
Item
For Data Managers or Monitors only: Require the investigator to re-sign the case book
boolean
C2346576 (UMLS CUI [1,1])
C0205341 (UMLS CUI [1,2])
C1514873 (UMLS CUI [1,3])
Item Group
Investigator Signature
C2346576 (UMLS CUI-1)
Investigator Signature
Item
Is this casebook ready to sign?
boolean
C2346576 (UMLS CUI [1])
Investigator Re-Sign required
Item
For Data Managers or Monitors only: Require the investigator to re-sign the case book
boolean
C2346576 (UMLS CUI [1,1])
C0205341 (UMLS CUI [1,2])
C1514873 (UMLS CUI [1,3])
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