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Screening - Screen Conclusion

1 forms  
Administrative
Description

Administrative

Alias
UMLS CUI-1
C1320722
Patient Number
Description

Patient Number

Data type

text

Alias
UMLS CUI [1]
C2348585
Screening Conclusion
Description

Screening Conclusion

Alias
UMLS CUI-1
C1710477
UMLS CUI-2
C1707478
Did the patient experience any Serious Adverse Event during screening?
Description

(only SAEs related to study participation or to a concurrent GSK medication need to be considered and reported).

Data type

boolean

Alias
UMLS CUI [1]
C1519255
Specify total number of SAEs:
Description

Specify total number of SAEs:

Data type

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C1519255
Is the patient a screening failure?
Description

(Was the patient withdrawn prior to treatment number allocation?)

Data type

boolean

Alias
UMLS CUI [1]
C1710476
Major reason for screening failure.
Description

(Tick one box only)

Data type

text

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C0566251
If major reason for screening failure is SAE, please specify SAE No.
Description

If major reason for screening failure is SAE, please specify SAE No.

Data type

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C2348235
If other reason for screening failure, specify
Description

If other reason for screening failure, specify

Data type

text

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C3840932
UMLS CUI [1,3]
C2348235
Who made the decision:
Description

Who made the decision:

Data type

text

Alias
UMLS CUI [1]
C0679006
Investigator's Signature
Description

Investigator's Signature

Alias
UMLS CUI-1
C2346576
Investigator's Signature
Description

I confirm that I have reviewed the data in these screening forms for this patient. All information entered by myself or my colleagues is, to the best of my knowledge, complete and accurate, as of the date below.

Data type

text

Alias
UMLS CUI [1]
C2346576
Printed Investigator's name:
Description

Printed Investigator's name:

Data type

text

Alias
UMLS CUI [1]
C2826892
Investigator's Signature Date
Description

Investigator's Signature Date

Data type

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
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Similar models

Screening - Screen Conclusion

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative
C1320722 (UMLS CUI-1)
Patient Number
Item
Patient Number
text
C2348585 (UMLS CUI [1])
Item Group
Screening Conclusion
C1710477 (UMLS CUI-1)
C1707478 (UMLS CUI-2)
Did the patient experience any Serious Adverse Event during screening?
Item
Did the patient experience any Serious Adverse Event during screening?
boolean
C1519255 (UMLS CUI [1])
Specify total number of SAEs:
Item
Specify total number of SAEs:
integer
C0449788 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Is the patient a screening failure?
Item
Is the patient a screening failure?
boolean
C1710476 (UMLS CUI [1])
Item
Major reason for screening failure.
text
C1710476 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Major reason for screening failure.
Code List
Major reason for screening failure.
CL Item
Death (any cause)  (DEA)
CL Item
Eligibility criteria not fulfilled (inclusion and exclusion criteria). Please tick failing criteria on Eligibility form.  (ELI)
CL Item
Serious adverse event: Please complete and submit SAE report. (SAE)
CL Item
Consent withdrawal not due to a serious adverse event.  (CWS)
CL Item
Migrated / moved from the study area.  (MIG)
CL Item
Other, please specify (OTH)
If major reason for screening failure is SAE, please specify SAE No.
Item
If major reason for screening failure is SAE, please specify SAE No.
integer
C1519255 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
If other reason for screening failure, specify
Item
If other reason for screening failure, specify
text
C1710476 (UMLS CUI [1,1])
C3840932 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Item
Who made the decision:
text
C0679006 (UMLS CUI [1])
Who made the decision:
Code List
Who made the decision:
CL Item
Investigator (I)
CL Item
Patient (S)
CL Item
Both (B)
Item Group
Investigator's Signature
C2346576 (UMLS CUI-1)
Investigator's Signature
Item
Investigator's Signature
text
C2346576 (UMLS CUI [1])
Printed Investigator's name:
Item
Printed Investigator's name:
text
C2826892 (UMLS CUI [1])
Investigator's Signature Date
Item
Investigator's Signature Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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