ID

41661

Beskrivning

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).

Länk

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

Nyckelord

Versioner (2)
  1. 2020-12-01 2020-12-01 -
  2. 2020-12-05 2020-12-05 -
Rättsinnehavare

GlaxoSmithKline

Uppladdad den

5 december 2020

DOI

För en begäran logga in.

Licens

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

Engelsk

Screening Conclusion

1 Formulär  
  1. StudyEvent: ODM
    1. Screening Conclusion
Administrative Data
Beskrivning

Administrative Data

Alias
UMLS CUI-1
C1320722
Centre number
Beskrivning

Centre number

Datatyp

text

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

Subject number

Datatyp

text

Alias
UMLS CUI [1]
C2348585
Treatment number
Beskrivning

Treatment number

Datatyp

text

Alias
UMLS CUI [1]
C1522541
Date of visit
Beskrivning

Date of visit

Datatyp

date

Alias
UMLS CUI [1]
C1320303
Screening Conclusion
Beskrivning

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)
Beskrivning

SAE during screening

Datatyp

text

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

Number of SAEs during screening

Datatyp

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?)
Beskrivning

Screen failure (withdrawn prior to randomization or first vaccination)

Datatyp

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)
Beskrivning

Major reason for screening failure

Datatyp

text

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

Reason for screening failure: protocol violation

Datatyp

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.
Beskrivning

Reason for screening failure: SAE

Datatyp

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
Beskrivning

Other reason for screening failure

Datatyp

text

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

Decision

Datatyp

text

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

Investigator's signature

Alias
UMLS CUI-1
C2346576
Investigator's signature
Beskrivning

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.

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Date
Beskrivning

Date of investigator's signature

Datatyp

date

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

Printed Investigator's name

Datatyp

text

Alias
UMLS CUI [1]
C2826892
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Similar models

Screening Conclusion

1 Formulär
  1. StudyEvent: ODM
    1. Screening Conclusion
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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