ID

41661

Descripción

Study ID: 105874 Clinical Study ID: 105874 Study Title: Bridging Safety & Immunogenicity Study of GSK Biologicals' Candidate Malaria Vaccine RTS,S/AS01E (0.5 mL Dose) to RTS,S/AS02D (0.5 mL Dose) Administered IM According to a 0, 1, 2-Month Schedule in Gabonese Children Aged 18 Months to 4 Years Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00307021 https://clinicaltrials.gov/ct2/show/NCT00307021 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 2 Study Recruitment Status: Completed Generic Name: GSK Biologicals' candidate Plasmodium falciparum malaria vaccine 257049 Trade Name: N/A Study Indication: Malaria This study has a total of 7 visits. Visit 1 = Screening, Visits 2-6 are during the double-blind phase (Month 0-3) and Visit 7 is during the single-blind phase (Month 4-14). This form (Screening Conclusion) is to be filled out at Visit 1 (Day -28 to day 0).

Link

https://clinicaltrials.gov/ct2/show/NCT00307021

Palabras clave

Versiones (2)
  1. 1/12/20 1/12/20 -
  2. 5/12/20 5/12/20 -
Titular de derechos de autor

GlaxoSmithKline

Subido en

5 de diciembre de 2020

DOI

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Licencia

Creative Commons BY-NC 4.0
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Safety & Immunogenicity of two GSK Biologicals' Candidate Malaria Vaccines in young children, NCT00307021

Inglés

Screening Conclusion

1 formularios  
  1. StudyEvent: ODM
    1. Screening Conclusion
Administrative Data
Descripción

Administrative Data

Alias
UMLS CUI-1
C1320722
Centre number
Descripción

Centre number

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0019994
Subject number
Descripción

Subject number

Tipo de datos

text

Alias
UMLS CUI [1]
C2348585
Treatment number
Descripción

Treatment number

Tipo de datos

text

Alias
UMLS CUI [1]
C1522541
Date of visit
Descripción

Date of visit

Tipo de datos

date

Alias
UMLS CUI [1]
C1320303
Screening Conclusion
Descripción

Screening Conclusion

Alias
UMLS CUI-1
C1710477
UMLS CUI-2
C1707478
Did the subject experience any Serious Adverse Event during screening? (only SAE related to study participation or to a concurrent medication need to be considered and reported)
Descripción

SAE during screening

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0347984
UMLS CUI [1,3]
C1710477
If yes, specify total number of SAEs
Descripción

Number of SAEs during screening

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C1519255
UMLS CUI [1,3]
C0347984
UMLS CUI [1,4]
C1710477
Is the subject a screening failure? (Was the subject withdrawn prior to randomization or first vaccination?)
Descripción

Screen failure (withdrawn prior to randomization or first vaccination)

Tipo de datos

text

Alias
UMLS CUI [1]
C1710476
UMLS CUI [2,1]
C0422727
UMLS CUI [2,2]
C0332152
UMLS CUI [2,3]
C0034656
UMLS CUI [3,1]
C0422727
UMLS CUI [3,2]
C0332152
UMLS CUI [3,3]
C0205435
UMLS CUI [3,4]
C0042196
If yes, provide Major reason for failure (tick one box only)
Descripción

Major reason for screening failure

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C1542147
UMLS CUI [1,3]
C0566251
If protocol violation, please specify
Descripción

Reason for screening failure: protocol violation

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C0566251
UMLS CUI [1,3]
C1709750
UMLS CUI [1,4]
C2348235
If SAE please specify SAE No.
Descripción

Reason for screening failure: SAE

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C1710476
UMLS CUI [1,2]
C0566251
UMLS CUI [1,3]
C1519255
UMLS CUI [1,4]
C0237753
If other reason, please specify
Descripción

Other reason for screening failure

Tipo de datos

text

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

Decision

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0679006
UMLS CUI [1,2]
C1710476
Investigator's signature
Descripción

Investigator's signature

Alias
UMLS CUI-1
C2346576
Investigator's signature
Descripción

I confirm that I have reviewed the data in this Case Report Form for this subject. All information entered by myself or my colleagues is, to the best of my knowledge, complete and accurate, as of the dat below.

Tipo de datos

text

Alias
UMLS CUI [1]
C2346576
Date
Descripción

Date of investigator's signature

Tipo de datos

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Printed Investigator's name
Descripción

Printed Investigator's name

Tipo de datos

text

Alias
UMLS CUI [1]
C2826892
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Similar models

Screening Conclusion

1 formularios
  1. StudyEvent: ODM
    1. Screening Conclusion
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Centre number
Item
Centre number
text
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Subject number
Item
Subject number
text
C2348585 (UMLS CUI [1])
Treatment number
Item
Treatment number
text
C1522541 (UMLS CUI [1])
Date of visit
Item
Date of visit
date
C1320303 (UMLS CUI [1])
Item Group
Screening Conclusion
C1710477 (UMLS CUI-1)
C1707478 (UMLS CUI-2)
Item
Did the subject experience any Serious Adverse Event during screening? (only SAE related to study participation or to a concurrent medication need to be considered and reported)
text
C1519255 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C1710477 (UMLS CUI [1,3])
SAE during screening
Code List
Did the subject experience any Serious Adverse Event during screening? (only SAE related to study participation or to a concurrent medication need to be considered and reported)
CL Item
No (N)
CL Item
Yes, specify total number of SAEs (Y)
Number of SAEs during screening
Item
If yes, specify total number of SAEs
integer
C0449788 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
C0347984 (UMLS CUI [1,3])
C1710477 (UMLS CUI [1,4])
Item
Is the subject a screening failure? (Was the subject withdrawn prior to randomization or first vaccination?)
text
C1710476 (UMLS CUI [1])
C0422727 (UMLS CUI [2,1])
C0332152 (UMLS CUI [2,2])
C0034656 (UMLS CUI [2,3])
C0422727 (UMLS CUI [3,1])
C0332152 (UMLS CUI [3,2])
C0205435 (UMLS CUI [3,3])
C0042196 (UMLS CUI [3,4])
Screen failure (withdrawn prior to randomization or first vaccination)
Code List
Is the subject a screening failure? (Was the subject withdrawn prior to randomization or first vaccination?)
CL Item
No (N)
CL Item
Yes, provide major reason for failure (Y)
Item
If yes, provide Major reason for failure (tick one box only)
text
C1710476 (UMLS CUI [1,1])
C1542147 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
Major reason for screening failure
Code List
If yes, provide Major reason for failure (tick one box only)
CL Item
Eligibility criteria not fulfilled (inclusion and exclusion criteria; please tick failing criteria on Eligibility form) (ELI)
CL Item
Protocol violation, please specify (PTV)
CL Item
Serious Adverse Event (please complete and submit SAE report and specify SAE No.) (SAE)
CL Item
Consent withdrawal / not willing to participate, not due to a serious adverse event (CWS)
CL Item
Migrated /moved from the study area (MIG)
CL Item
Lost to follow-up (LFU)
CL Item
Other, please specify (OTH)
Reason for screening failure: protocol violation
Item
If protocol violation, please specify
text
C1710476 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
C1709750 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
Reason for screening failure: SAE
Item
If SAE please specify SAE No.
integer
C1710476 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,3])
C0237753 (UMLS CUI [1,4])
Other reason for screening failure
Item
If other reason, please 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 [1,1])
C1710476 (UMLS CUI [1,2])
Decision
Code List
Who made the decision?
CL Item
Investigator (I)
CL Item
Parents/Guardian (P)
Item Group
Investigator's signature
C2346576 (UMLS CUI-1)
Investigator's signature
Item
Investigator's signature
text
C2346576 (UMLS CUI [1])
Date of investigator's signature
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Printed Investigator's name
Item
Printed Investigator's name
text
C2826892 (UMLS CUI [1])
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