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GSK TWINRIX™ Hepatitis A and B Vaccine: Persistence of Immune Response in 0,6 Month vs. 0,1,6 Month Schedule NCT00197119 - Longterm Follow-up Visit 14

1 Formulär  
Informed consent
Beskrivning

Informed consent

Alias
UMLS CUI-1
C0021430
Informed Consent Date
Beskrivning

I certify that Informed Consent has been obtained prior to any study procedure.

Datatyp

date

Alias
UMLS CUI [1]
C2985782
Demographics
Beskrivning

Demographics

Alias
UMLS CUI-1
C1704791
Center number
Beskrivning

LONG-TERM FOLLOW-UP PREVIOUS STUDY 208127/106 (EXT HAB-084) – Month 60 Subject number will be the same as in the previous study.

Datatyp

text

Alias
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0600091
Date of Birth
Beskrivning

Date of Birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Gender
Beskrivning

Gender

Datatyp

text

Alias
UMLS CUI [1]
C0079399
Laboratory Tests
Beskrivning

Laboratory Tests

Alias
UMLS CUI-1
C0022885
Has a blood sample been taken for testing anti-HAV and anti-HBs antibodies?
Beskrivning

Blood sample taken for testing anti-HAV or anti-HBs

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1277698
UMLS CUI [1,2]
C0201473
UMLS CUI [2,1]
C1277698
UMLS CUI [2,2]
C0201478
Date blood sample was taken
Beskrivning

Only answer if blood sample for testing anti-HAV or anti-HBs was taken and if the date the blood sample was taken is different from visit date.

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0005834
Has the subject received since the last visit: A dose of monovalent or combined Hepatitis A or Hepatitis B vaccine?
Beskrivning

A dose of monovalent or combined Hepatitis A or Hepatitis B vaccine

Datatyp

boolean

Alias
UMLS CUI [1]
C0170300
UMLS CUI [2]
C2240392
UMLS CUI [3]
C5397396
Follow-up studies
Beskrivning

Follow-up studies

Alias
UMLS CUI-1
C0016441
UMLS CUI-2
C0042210
Would the subject be willing to participate in a follow-up study?
Beskrivning

Would the subject be willing to participate in a follow-up study?

Datatyp

integer

Alias
UMLS CUI [1,1]
C0016441
UMLS CUI [1,2]
C2348568
UMLS CUI [1,3]
C0600109
Please specify the most appropriate reason
Beskrivning

I you answered previous question with 'no' please specify the most appropriate reason.

Datatyp

text

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C0392360
Please specify Adverse Event or Serious adverse event.
Beskrivning

Please specify Adverse Event or Serious adverse event

Datatyp

text

Alias
UMLS CUI [1,1]
C0559546
UMLS CUI [1,2]
C1521902
UMLS CUI [2,1]
C1519255
UMLS CUI [2,2]
C1521902
Please specify other reason for not willing to participate in follow-up studies
Beskrivning

other reason for non-participation

Datatyp

text

Alias
UMLS CUI [1,1]
C3840932
UMLS CUI [1,2]
C1521902
Did the Subject experience any SAE since Last Visit?
Beskrivning

serious adverse event since last visit

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C2047944
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 date below.

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Investigator signature date
Beskrivning

Investigator signature date

Datatyp

date

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

Investigator name

Datatyp

text

Alias
UMLS CUI [1]
C2826892
Tracking Document - Reason for non participation
Beskrivning

Tracking Document - Reason for non participation

Alias
UMLS CUI-1
C2348568
UMLS CUI-2
C0392360
Previous subject number
Beskrivning

Previous subject number

Datatyp

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C0205156
Date of birth
Beskrivning

Date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Please document reason for non participation
Beskrivning

reason for non participation

Datatyp

integer

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C0392360
Subject not eligible? - please specify criteria that are not full-filled.
Beskrivning

If you chose 'Subject not eligible' as reason for non participation, please specify.

Datatyp

text

Alias
UMLS CUI [1,1]
C3828770
UMLS CUI [1,2]
C1521902
Subject eligible but not willing to participate due to:
Beskrivning

Only, answer this question, if you chose 'Subject eligible but not willing to participate' as reason for non participation.

Datatyp

integer

Alias
UMLS CUI [1,1]
C3846156
UMLS CUI [1,2]
C0392360
Please specify 'adverse events or serious adverse event'.
Beskrivning

If you chose 'adverse events or serious adverse event', please specify.

Datatyp

text

Alias
UMLS CUI [1,1]
C0559546
UMLS CUI [1,2]
C1521902
UMLS CUI [2,1]
C1519255
UMLS CUI [2,2]
C1521902
Please specify 'other'.
Beskrivning

Please specify 'other' reason for eligible but not-willing to participate in study.

Datatyp

text

Alias
UMLS CUI [1,1]
C3840932
UMLS CUI [1,2]
C1521902
Subject died on:
Beskrivning

Please fill in Date of death, if you chose 'subject died on' as reason for non participation

Datatyp

date

Alias
UMLS CUI [1]
C1148348
Date of contact
Beskrivning

Date of contact

Datatyp

date

Alias
UMLS CUI [1]
C0805839
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Similar models

GSK TWINRIX™ Hepatitis A and B Vaccine: Persistence of Immune Response in 0,6 Month vs. 0,1,6 Month Schedule NCT00197119 - Longterm Follow-up Visit 14

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Informed consent
C0021430 (UMLS CUI-1)
Informed consent date
Item
Informed Consent Date
date
C2985782 (UMLS CUI [1])
Item Group
Demographics
C1704791 (UMLS CUI-1)
Center number
Item
Center number
text
C1301943 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date of Birth
Item
Date of Birth
date
C0421451 (UMLS CUI [1])
Item
Gender
text
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
Male (M)
CL Item
Female (F)
Item Group
Laboratory Tests
C0022885 (UMLS CUI-1)
Blood sample taken for testing anti-HAV or anti-HBs
Item
Has a blood sample been taken for testing anti-HAV and anti-HBs antibodies?
boolean
C1277698 (UMLS CUI [1,1])
C0201473 (UMLS CUI [1,2])
C1277698 (UMLS CUI [2,1])
C0201478 (UMLS CUI [2,2])
Blood sample date
Item
Date blood sample was taken
date
C0011008 (UMLS CUI [1,1])
C0005834 (UMLS CUI [1,2])
A dose of monovalent or combined Hepatitis A or Hepatitis B vaccine
Item
Has the subject received since the last visit: A dose of monovalent or combined Hepatitis A or Hepatitis B vaccine?
boolean
C0170300 (UMLS CUI [1])
C2240392 (UMLS CUI [2])
C5397396 (UMLS CUI [3])
Item Group
Follow-up studies
C0016441 (UMLS CUI-1)
C0042210 (UMLS CUI-2)
Item
Would the subject be willing to participate in a follow-up study?
integer
C0016441 (UMLS CUI [1,1])
C2348568 (UMLS CUI [1,2])
C0600109 (UMLS CUI [1,3])
Would the subject be willing to participate in a follow-up study?
Code List
Would the subject be willing to participate in a follow-up study?
CL Item
Yes (1)
CL Item
No (2)
Item
Please specify the most appropriate reason
text
C2348568 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
undefined item
Code List
Please specify the most appropriate reason
CL Item
Adverse Events or Serious adverse event (1)
CL Item
Other (2)
Please specify Adverse Event or Serious adverse event
Item
Please specify Adverse Event or Serious adverse event.
text
C0559546 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
C1519255 (UMLS CUI [2,1])
C1521902 (UMLS CUI [2,2])
other reason for non-participation
Item
Please specify other reason for not willing to participate in follow-up studies
text
C3840932 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
serious adverse event since last visit
Item
Did the Subject experience any SAE since Last Visit?
boolean
C1519255 (UMLS CUI [1,1])
C2047944 (UMLS CUI [1,2])
Item Group
Investigator's signature
C2346576 (UMLS CUI-1)
Investigator signature
Item
Investigator's signature
text
C2346576 (UMLS CUI [1])
Investigator signature date
Item
Investigator signature date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator name
Item
Printed Investigator's name
text
C2826892 (UMLS CUI [1])
Item Group
Tracking Document - Reason for non participation
C2348568 (UMLS CUI-1)
C0392360 (UMLS CUI-2)
Previous subject number
Item
Previous subject number
text
C2348585 (UMLS CUI [1,1])
C0205156 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Please document reason for non participation
integer
C2348568 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
reason for non participation
Code List
Please document reason for non participation
CL Item
Subject not eligible? - please specify criteria that are not full-filled: (1)
CL Item
Subject lost to follow-up or not reached (2)
CL Item
Subject eligible but not willing to participate due to: (3)
CL Item
Subject died on: (4)
subject not meeting criteria please specify
Item
Subject not eligible? - please specify criteria that are not full-filled.
text
C3828770 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
Item
Subject eligible but not willing to participate due to:
integer
C3846156 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Eligible but Refused due to
Code List
Subject eligible but not willing to participate due to:
CL Item
adverse events, or serious adverse event (1)
CL Item
other (2)
specify adverse events or serious adverse event
Item
Please specify 'adverse events or serious adverse event'.
text
C0559546 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
C1519255 (UMLS CUI [2,1])
C1521902 (UMLS CUI [2,2])
specify other reason
Item
Please specify 'other'.
text
C3840932 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
Date of death
Item
Subject died on:
date
C1148348 (UMLS CUI [1])
Date of contact
Item
Date of contact
date
C0805839 (UMLS CUI [1])
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