Engels

Check for Study Continuation

1 Formulieren  
Administrative Documentation
Beschrijving

Administrative Documentation

Alias
UMLS CUI-1
C1320722
Visit number
Beschrijving

Visit number

Datatype

integer

Alias
UMLS CUI [1]
C1549755
Date of visit
Beschrijving

Date of visit

Datatype

date

Alias
UMLS CUI [1]
C1320303
Subject number
Beschrijving

Subject number

Datatype

integer

Alias
UMLS CUI [1]
C2348585
Check for Study Continuation
Beschrijving

Check for Study Continuation

Alias
UMLS CUI-1
C0805733
UMLS CUI-2
C0008976
Did the subject return for the above-specified visit?
Beschrijving

If yes, please complete the forms for this visit. If no, please complete this form and skip the other forms for this visit.

Datatype

boolean

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C0805733
UMLS CUI [1,3]
C0008976
If no, same reason and decision as previous visit?
Beschrijving

Only possible to tick at visits 3, 4, 5, 6, or 7. For visit 2 OR if withdrawal reason and justification are not equal to the previous visit, please fill in the following question in this form.

Datatype

boolean

Alias
UMLS CUI [1,1]
C0457454
UMLS CUI [1,2]
C0008976
UMLS CUI [1,3]
C0566251
UMLS CUI [1,4]
C0205225
UMLS CUI [1,5]
C2127115
UMLS CUI [2,1]
C0457454
UMLS CUI [2,2]
C0008976
UMLS CUI [2,3]
C0679006
UMLS CUI [2,4]
C2127115
If no, please tick the ONE most appropriate reason and skip the following forms of this visit.
Beschrijving

Discontinuation clinical trial primary reason and justification

Datatype

text

Alias
UMLS CUI [1,1]
C0457454
UMLS CUI [1,2]
C0008976
UMLS CUI [1,3]
C0566251
UMLS CUI [1,4]
C0205225
If serious adverse event [SAE], please specify SAE N°.
Beschrijving

If serious adverse event [SAE], please also complete the SAE form.

Datatype

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C1521902
If non-serious adverse event [AEX], please specify AE N°.
Beschrijving

If non-serious adverse event [AEX], please also complete the non-serious adverse event section.

Datatype

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C1521902
If other [OTH], please specify (e.g.: consent withdrawal, protocol violation, …).
Beschrijving

Discontinuation clinical trial primary reason to specify | consent withdrawal | protocol violation

Datatype

text

Alias
UMLS CUI [1,1]
C0457454
UMLS CUI [1,2]
C0008976
UMLS CUI [1,3]
C0566251
UMLS CUI [1,4]
C0205225
UMLS CUI [1,5]
C1521902
UMLS CUI [2]
C1707492
UMLS CUI [3]
C1709750
Please tick who made the decision.
Beschrijving

Discontinuation clinical trial decision maker

Datatype

text

Alias
UMLS CUI [1,1]
C0457454
UMLS CUI [1,2]
C0008976
UMLS CUI [1,3]
C0679006
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Similar models

Check for Study Continuation

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative Documentation
C1320722 (UMLS CUI-1)
Item
Visit number
integer
C1549755 (UMLS CUI [1])
Visit number
Code List
Visit number
CL Item
clinical visit 2 (2)
CL Item
clinical visit 3 (3)
CL Item
clinical visit 4 (4)
CL Item
clinical visit 5 (5)
CL Item
clinical visit 6 (6)
CL Item
clinical visit 7 (7)
Date of visit
Item
Date of visit
date
C1320303 (UMLS CUI [1])
Subject number
Item
Subject number
integer
C2348585 (UMLS CUI [1])
Item Group
Check for Study Continuation
C0805733 (UMLS CUI-1)
C0008976 (UMLS CUI-2)
Visit continuation status clinical trial
Item
Did the subject return for the above-specified visit?
boolean
C0545082 (UMLS CUI [1,1])
C0805733 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
Discontinuation clinical trial primary reason justification and decision unchanged from previous visit
Item
If no, same reason and decision as previous visit?
boolean
C0457454 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
C0205225 (UMLS CUI [1,4])
C2127115 (UMLS CUI [1,5])
C0457454 (UMLS CUI [2,1])
C0008976 (UMLS CUI [2,2])
C0679006 (UMLS CUI [2,3])
C2127115 (UMLS CUI [2,4])
Item
If no, please tick the ONE most appropriate reason and skip the following forms of this visit.
text
C0457454 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
C0205225 (UMLS CUI [1,4])
Patient withdrawn from trial, reason justification, primary
Code List
If no, please tick the ONE most appropriate reason and skip the following forms of this visit.
CL Item
Serious adverse event ([SAE])
CL Item
Non-serious Adverse Event ([AEX])
CL Item
Other ([OTH])
Serious adverse event number to specify
Item
If serious adverse event [SAE], please specify SAE N°.
integer
C1519255 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Non-serious adverse event number to specify
Item
If non-serious adverse event [AEX], please specify AE N°.
integer
C1518404 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Discontinuation clinical trial primary reason to specify | consent withdrawal | protocol violation
Item
If other [OTH], please specify (e.g.: consent withdrawal, protocol violation, …).
text
C0457454 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
C0205225 (UMLS CUI [1,4])
C1521902 (UMLS CUI [1,5])
C1707492 (UMLS CUI [2])
C1709750 (UMLS CUI [3])
Item
Please tick who made the decision.
text
C0457454 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
C0679006 (UMLS CUI [1,3])
Withdrawal decision maker
Code List
Please tick who made the decision.
CL Item
Investigator  ([I])
CL Item
Parents/Guardians ([P])
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