Demographics
LONG-TERM FOLLOW-UP PREVIOUS STUDY 208127/106 (EXT HAB-084) – Month 60 Subject number will be the same as in the previous study.
text
Date of Birth
date
Gender
text
Laboratory Tests
Blood sample taken for testing anti-HAV or anti-HBs
boolean
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.
date
A dose of monovalent or combined Hepatitis A or Hepatitis B vaccine
boolean
Follow-up studies
Would the subject be willing to participate in a follow-up study?
integer
I you answered previous question with 'no' please specify the most appropriate reason.
text
Please specify Adverse Event or Serious adverse event
text
other reason for non-participation
text
Occurrence of serious adverse event
Serious Adverse Event during the study period
boolean
Only answer if you answered last question with 'yes'.
integer
Investigator's signature
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.
text
Investigator signature date
date
Investigator name
text
Tracking Document - Reason for non participation
Previous subject number
text
Date of birth
date
reason for non participation
integer
If you chose 'Subject not eligible' as reason for non participation, please specify.
text
Only, answer this question, if you chose 'Subject eligible but not willing to participate' as reason for non participation.
integer
If you chose 'adverse events or serious adverse event', please specify.
text
Please specify 'other' reason for eligible but not-willing to participate in study.
text
Please fill in Date of death, if you chose 'subject died on' as reason for non participation
date
Date of contact
date