Type of report
Randomisation
Serious Adverse Event (SAE)
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text
Diagnosis Only (if known) Otherwise Sign/Symptom. An SAE is any untoward medical occurrence that, at any dose: - Results in death - Is life-threatening - Requires hospitalization or prolongation of existing hospitalization. - Results in disability/incapacity, or - Is a congenital anomaly/birth defect - Medical or scientific judgment should be exercised in deciding whether reporting is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but may jeopardize the subject or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. These should also be considered serious. Examples of such events are invasive or malignant cancers, intensive treatment in an emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalization, or development of drug dependency or drug abuse. - Is associated with liver injury and impaired liver function defined as: ALT ≥ 3xULN, and total bilirubin ≥ 2xULN or INR > 1.5.
text
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text
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boolean
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boolean
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boolean
day month year
partialDate
00:00-23:9
time
If you tick "Recovered/Resolved" or "Recovered/Resolved with sequelae", provide End Date and Time in the appropriate items. If you tick "Fatal", record Date and Time of death in the appropriate items.
integer
day month year
partialDate
00:00-23:59
time
day month year
partialDate
00:00-23:59
time
Mild: An event which is easily tolerated Moderate: An event which is sufficiently discomforting to interfere with daily activity Severe: An event which prevents normal everyday activities.
text
SAE Maximum Grade
text
SAE Maximum Grade or Intensity
text
Action Taken with Investigational Product(s) as a Result of the AE
text
Subject withdrawn
text
Relationship to Investigational Drug
text
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integer
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integer
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integer
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integer
SAE caused by activities related to study participation
text
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text
Seriousness of SAE
Results in death
boolean
NOTE: The term 'life-threatening' in the definition of 'serious' refers to an event in which the subject was at risk of death at the time of the event. It does not refer to an event, which hypothetically might have caused death, if it were more severe.
boolean
NOTE: In general, hospitalisation signifies that the subject has been detained (usually involving at least an overnight stay) at the hospital or emergency ward for observation and/or treatment that would not have been appropriate in the physician's office or out-patient setting. Complications that occur during hospitalisation are AEs. If a complication prolongs hospitalisation or fulfils any other serious criteria, the event is serious. When in doubt as to whether ,,hospitalisation" occurred or was necessary, the AE should be considered serious. Hospitalisation for elective treatment ofa pre-existing condition that did not worsen from baseline is not considered anAE.
boolean
NOTE: The term disability means a substantial disruption ofa person's ability to conduct normal life functions. This definition is not intended to include experiences of relatively minor medical significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life functions but do not consitute a substantial disruption.
boolean
Congenital anomaly/birth defect
boolean
Medical or scientific judgement should be exercised in deciding whether reporting is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalisation but may jeopardize the subject or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. These should also be considered serious. Examples of such events are invasive or malignant cancers, intensive treatment in an emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalisation, or development of drug dependency or drug abuse.
boolean
Other reason, specification
text
Relevant concomitant/ treatment medications
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integer
(Trade Name preferred)
text
Dose of drug
text
Unit
text
Frequency of medication
text
Route of medication
text
day month year
partialDate
Medication ongoing
text
day month year
partialDate
Primary Indication of medication
text
Drug type
text
Relevant medical conditions/ risk factors
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integer
Specific Condition Name
text
day month year
partialDate
Disease continuing
text
day month year
partialDate
Other Relevant Medical History/ Risk Factors
text
Relevant diagnostic results
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integer
Test Name
text
day month year
partialDate
Test Result
text
Test Units
text
Normal Low Range
text
Normal High Range
text
Other relevant diagnostic results
text
Investigational product
Recurrence of event after further investigational product(s) administration
text
General narrative comments
Provide a brief narrative description of SAE, possible other causes of the event (e.g. lac of efficacy, withdrawal of investigational product, the disease under study or other medical conditions) and details of the treatment.
text
Non clinical
Send incomplete SAE data to GSK Safety. In the original form this item is hidden.
boolean
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date
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text
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integer
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integer
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integer
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integer
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text
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text