Inglés

Serious adverse events GSK study Dyskinesia in Parkinson's disease NCT00363727

1 formularios  
General information
Descripción

General information

Protocol identifier
Descripción

Protocol identifier

Tipo de datos

integer

Alias
UMLS CUI [1]
C2826693
Subject Identifier
Descripción

Subject Identifier

Tipo de datos

text

Alias
UMLS CUI [1]
C2348585
Centre
Descripción

Centre

Tipo de datos

integer

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

Randomization number

Tipo de datos

integer

Alias
UMLS CUI [1]
C2986235
Serious adverse events
Descripción

Serious adverse events

Did the subject experience a serious adverse event during the study?
Descripción

If Yes, record details below.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1519255
Section 1
Descripción

Section 1

Event
Descripción

Record one SAE diagnosis per line, or a sign/symptom if the diagnosis is not available. If a diagnosis subsequently becomes available, this then should be entered and the sign/symptom crossed out, initialled and dated by the investigator. A separate form should be used for each SAE however if multiple SAEs which are temporally or clinically related are apparent at the time of initial reporting then these may be reported on the same page.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0877248
Start date
Descripción

Record the start date of the first occurrence of the SAE.

Tipo de datos

date

Alias
UMLS CUI [1]
C0808070
Outcome
Descripción

All SAEs must be followed until the events are resolved, the condition stabilises, the events are otherwise explained, or the subject is lost to follow-up. Indicate if the event was ’Recovered/Resolved’ or ’Recovered/Resolved with sequelae’. If the SAE is ongoing at the time the subject completes the study or becomes lost to follow-up, the outcome must be recorded as ’Not recovered/Not resolved’ or ’Recovering/Resolving’. Also enter ’Not recovered/Not resolved’ if the SAE was ongoing at the time of death, but was not the cause of death, enter fatal for the SAE which was the direct cause of death.

Tipo de datos

integer

Alias
UMLS CUI [1]
C1705586
End Date
Descripción

Record the end date. This is the date the SAE Recovered/Resolved, or if the outcome was fatal, record the date the subject died. If the event Recovered/ Resolved with sequelae, enter the date the subject’s medical condition resolved or stabilised. Leave blank if the SAE is ’Not recovered/Not resolved’ or ’Recovering/Resolving’.

Tipo de datos

date

Alias
UMLS CUI [1]
C0806020
Maximum Intensity
Descripción

Record the maximum intensity that occurred over the duration of the event. Amend the intensity if it increases. Mild = An event that is easily tolerated by the subject, causing minimal discomfort and not interfering with everyday activities. Moderate = An event that is sufficiently discomforting to interfere with everyday activities. Severe = An event that prevents normal everyday activities. Not applicable = Those event(s) where intensity is meaningless or impossible to determine (i.e., blindness and coma).

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C0877248
Action Taken with Investigational Product(s) as a Result of the SAE
Descripción

Investigational product(s) withdrawn = Administration of investigational product(s) was permanently discontinued. Dose reduced =Dose is reduced for one or more investigational product(s). Dose increased =Dose increased for one or more investigational product(s). Dose not changed=Investigational product(s) continues even though an adverse event has occurred. Dose interrupted=Administration of one or more investigational product(s) was temporarily interrupted but then restarted. Not applicable=Subject was not receiving investigational product(s) when the event occurred (e.g., pre-or post-dosing) or the subject died and there was no prior decision to discontinue IP(s).

Tipo de datos

text

Alias
UMLS CUI [1]
C2826626
Did the subject withdraw from study as a result of this SAE?
Descripción

Indicate ’Yes’ if the event(s) were directly responsible for the subject’s withdrawal as indicated on the Study Conclusion page, otherwise indicate ’No’.

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C1519255
Is there a reasonable possibility that the SAE may have been caused by the investigational product?
Descripción

It is a regulatory requirement for investigators to assess relationship to investigational product(s) based on information available. The assessment should be reviewed on receipt of any new information and amended if necessary. ’A reasonable possibility’ is meant to convey that there are facts/evidence or arguments to suggest a causal relationship. Facts/evidence or arguments that may support ’a reasonable possibility’ include, e.g., a temporal relationship, a pharmacologically-predicted event, or positive dechallenge or rechallenge. Confounding factors, such as concomitant medication, a concurrent illness, or relevant medical history, should also be considered.

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0085978
UMLS CUI [1,2]
C0877248
If fatal, was a post-mortem/autopsy performed?
Descripción

If Yes, summarise findings in Section 11 Narrative Remarks of this SAE form.

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0004398
UMLS CUI [1,2]
C1519255
Section 2: Seriousness
Descripción

Section 2: Seriousness

[A] Results in death
Descripción

SAE results in death

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0011065
[B] Is life-threatening
Descripción

SAE is life-threatening

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2826244
[C] Requires hospitalisation or prolongation of existing hospitalisation
Descripción

SAE requires hospitalisation

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0019993
[D] Results in disability/incapacity
Descripción

SAE results in disability/incapacity

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0231170
[E] Congenital anomaly/birth defect
Descripción

Congenital anomaly/birth defect

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0000768
[F] Other
Descripción

Óther SAE

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1880177
Other, specify
Descripción

Other SAE specificationn

Tipo de datos

text

Alias
UMLS CUI [1]
C3845569
Section 3: Demography data
Descripción

Section 3: Demography data

Date of birth
Descripción

Date of birth

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Sex
Descripción

Sex

Tipo de datos

text

Alias
UMLS CUI [1]
C0079399
Weight
Descripción

Weight

Tipo de datos

float

Unidades de medida
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Section 4
Descripción

Section 4

If Investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further Investigational Product(s) were Administered?
Descripción

If deliberate or inadvertant administration of further dose(s) of investigational product(s) to the subject occurred, did the reported adverse event recur?

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0034897
Section 5: Possible Causes of SAE Other Than Investigational Product(s)
Descripción

Section 5: Possible Causes of SAE Other Than Investigational Product(s)

Disease under study
Descripción

Disease under study

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0012634
Medical condition(s) (record in Section 6)
Descripción

Medical condition

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1699700
Lack of efficacy
Descripción

Lack of efficacy

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0235828
Withdrawal of investigational product(s)
Descripción

Withdrawal of investigational product

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C0013227
Concomitant medication (record in Section 8)
Descripción

Concomitant medication

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2347852
Activity related to study participation (e.g., procedures)
Descripción

Activity related to study participation

Tipo de datos

boolean

Other
Descripción

Other cause of SAE

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0205394
Other, specify
Descripción

Other cause of SAE specification

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1707811
UMLS CUI [1,2]
C3840932
Section 6: Relevant medical conditions
Descripción

Section 6: Relevant medical conditions

Specify any RELEVANT past or current medical disorders, allergies, surgeries, etc. that can help explain the SAE
Descripción

Medical conditions relevant to SAE

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C1519255
Date of onset
Descripción

Date of onset

Tipo de datos

date

Alias
UMLS CUI [1]
C0574845
Condition Present at Time of the SAE?
Descripción

Condition Present at time of SAE

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0012634
UMLS CUI [1,2]
C1519255
If No, Date of Last Occurrence
Descripción

Date of Last Occurrence

Tipo de datos

date

Alias
UMLS CUI [1,1]
C2745955
UMLS CUI [1,2]
C0012634
UMLS CUI [1,3]
C0011008
UMLS CUI [1,4]
C1519255
Section 7
Descripción

Section 7

Other RELEVANT Risk Factors (provide any family or social history (e.g., smoking, alcohol, diet, drug abuse, occupational hazard) relevant to the SAE)
Descripción

Other risk factors relevant to SAE

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0035648
UMLS CUI [1,2]
C1519255
Section 8: RELEVANT Concomitant Medications (include details of any concomitant medication(s) which may have contributed to the event)
Descripción

Section 8: RELEVANT Concomitant Medications (include details of any concomitant medication(s) which may have contributed to the event)

Drug name
Descripción

(Trade Name preferred)

Tipo de datos

text

Alias
UMLS CUI [1]
C0013227
Dose
Descripción

Dose

Tipo de datos

float

Alias
UMLS CUI [1]
C3174092
Unit
Descripción

Unit

Tipo de datos

text

Alias
UMLS CUI [1]
C1519795
Frequency
Descripción

Frequency

Tipo de datos

float

Alias
UMLS CUI [1]
C3476109
Route
Descripción

Route

Tipo de datos

integer

Alias
UMLS CUI [1]
C0013153
Taken prior to study?
Descripción

medication taken prior to study

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2826667
Start date
Descripción

Start date

Tipo de datos

date

Alias
UMLS CUI [1]
C0808070
Stop Date
Descripción

Stop Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0806020
Ongoing Medication?
Descripción

Ongoing Medication

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2826666
Reason for Medication
Descripción

Reason for Medication

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C2347852
Section 9: Details of Investigational Product(s)
Descripción

Section 9: Details of Investigational Product(s)

Dose level randomization
Descripción

Dose level randomization

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0178602
UMLS CUI [1,2]
C0034656
Start date (randomization)
Descripción

Start date randomization

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0034656
UMLS CUI [1,2]
C0808070
Stop date (randomization)
Descripción

Stop date randomization

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0034656
UMLS CUI [1,2]
C2598418
Continuing (randomization)
Descripción

Continuation randomization

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0034656
UMLS CUI [1,2]
C1553904
Dose level At time of SAE
Descripción

Dose level At time of SAE

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0178602
UMLS CUI [1,2]
C1519255
Start date (At time of SAE)
Descripción

Start date At time of SAE

Tipo de datos

date

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0808070
Stop date (At time of SAE)
Descripción

Stop date At time of SAE

Tipo de datos

date

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C2598418
Continuing (At time of SAE)
Descripción

Continuation At time of SAE

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C1553904
Was randomisation code broken at investigational site?
Descripción

randomisation code broken

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0034656
UMLS CUI [1,2]
C3846431
Section 10
Descripción

Section 10

Details of RELEVANT Assessments (provide details of any other tests/procedures which were carried out to diagnose or confirm the SAE e.g., laboratory data with units and normal range)
Descripción

Details of relevant assessments

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1261322
UMLS CUI [1,2]
C1519255
Section 11
Descripción

Section 11

Narrative Remarks (provide a brief narrative description of the SAE and details of treatment given)
Descripción

Narrative Remarks

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1519255
Investigator information
Descripción

Investigator information

Investigator’s signature
Descripción

confirming that the data on the SAE pages are accurate and complete

Tipo de datos

text

Alias
UMLS CUI [1]
C2346576
Date
Descripción

Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0011008
Investigator’s name
Descripción

Investigator’s name

Tipo de datos

text

Alias
UMLS CUI [1]
C2826892
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Serious adverse events GSK study Dyskinesia in Parkinson's disease NCT00363727

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
General information
Protocol identifier
Item
Protocol identifier
integer
C2826693 (UMLS CUI [1])
Subject Identifier
Item
Subject Identifier
text
C2348585 (UMLS CUI [1])
Centre
Item
Centre
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Randomization number
Item
Randomization number
integer
C2986235 (UMLS CUI [1])
Item Group
Serious adverse events
serious adverse events
Item
Did the subject experience a serious adverse event during the study?
boolean
C1519255 (UMLS CUI [1])
Event
Item
Event
boolean
C0877248 (UMLS CUI [1])
Start date
Item
Start date
date
C0808070 (UMLS CUI [1])
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Recovered/Resolved (1)
C1709863 (UMLS CUI-1)
(Comment:en)
CL Item
Recovering/Resolving (2)
C1709864 (UMLS CUI-1)
(Comment:en)
CL Item
Not recovered/Not resolved (3)
(Comment:en)
CL Item
Recovered/Resolved with sequelae (4)
C1709862 (UMLS CUI-1)
(Comment:en)
CL Item
Fatal (5)
C1705586 (UMLS CUI-1)
C0004398 (UMLS CUI-2)
(Comment:en)
End Date
Item
End Date
date
C0806020 (UMLS CUI [1])
Item
Maximum Intensity
text
C0518690 (UMLS CUI [1,1])
C0877248 (UMLS CUI [1,2])
Maximum Intensity
Code List
Maximum Intensity
CL Item
Mild (1)
C2945599 (UMLS CUI-1)
(Comment:en)
CL Item
Moderate (2)
C0205081 (UMLS CUI-1)
(Comment:en)
CL Item
Severe (3)
C0205082 (UMLS CUI-1)
(Comment:en)
CL Item
Not applicable (X)
C1272460 (UMLS CUI-1)
(Comment:en)
Item
Action Taken with Investigational Product(s) as a Result of the SAE
text
C2826626 (UMLS CUI [1])
Action Taken
Code List
Action Taken with Investigational Product(s) as a Result of the SAE
CL Item
Investigational product(s) withdrawn (1)
C0013230 (UMLS CUI-1)
(Comment:en)
CL Item
Dose reduced (2)
C1707814 (UMLS CUI-1)
(Comment:en)
CL Item
Dose increased (3)
C1707810 (UMLS CUI-1)
(Comment:en)
CL Item
Dose not changed (4)
C0178602 (UMLS CUI-1)
C0442739 (UMLS CUI-2)
(Comment:en)
CL Item
Dose interrupted (5)
C0178602 (UMLS CUI-1)
C0443239 (UMLS CUI-2)
(Comment:en)
CL Item
Not applicable (X)
C1272460 (UMLS CUI-1)
(Comment:en)
withdrawal
Item
Did the subject withdraw from study as a result of this SAE?
boolean
C2349954 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Relationship to Investigational Product
Item
Is there a reasonable possibility that the SAE may have been caused by the investigational product?
boolean
C0085978 (UMLS CUI [1,1])
C0877248 (UMLS CUI [1,2])
post-mortem/autopsy
Item
If fatal, was a post-mortem/autopsy performed?
boolean
C0004398 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item Group
Section 2: Seriousness
SAE results in death
Item
[A] Results in death
boolean
C0011065 (UMLS CUI [1])
SAE is life-threatening
Item
[B] Is life-threatening
boolean
C2826244 (UMLS CUI [1])
SAE requires hospitalisation
Item
[C] Requires hospitalisation or prolongation of existing hospitalisation
boolean
C0019993 (UMLS CUI [1])
SAE results in disability/incapacity
Item
[D] Results in disability/incapacity
boolean
C0231170 (UMLS CUI [1])
Congenital anomaly/birth defect
Item
[E] Congenital anomaly/birth defect
boolean
C0000768 (UMLS CUI [1])
Óther SAE
Item
[F] Other
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
Other SAE specificationn
Item
Other, specify
text
C3845569 (UMLS CUI [1])
Item Group
Section 3: Demography data
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Sex
text
C0079399 (UMLS CUI [1])
Sex
Code List
Sex
CL Item
Male (Male)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
Female (Female)
C0086287 (UMLS CUI-1)
(Comment:en)
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Item Group
Section 4
Item
If Investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further Investigational Product(s) were Administered?
text
C0877248 (UMLS CUI [1,1])
C0034897 (UMLS CUI [1,2])
Recurrence of SAE
Code List
If Investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further Investigational Product(s) were Administered?
CL Item
Yes (Yes)
C1705108 (UMLS CUI-1)
(Comment:en)
CL Item
No (No)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Unknown at this time (Unknown at this time)
(Comment:en)
CL Item
Not applicable (Not applicable)
C1272460 (UMLS CUI-1)
(Comment:en)
Item Group
Section 5: Possible Causes of SAE Other Than Investigational Product(s)
Disease under study
Item
Disease under study
boolean
C0012634 (UMLS CUI [1])
Medical condition
Item
Medical condition(s) (record in Section 6)
boolean
C1699700 (UMLS CUI [1])
Lack of efficacy
Item
Lack of efficacy
boolean
C0235828 (UMLS CUI [1])
Withdrawal of investigational product
Item
Withdrawal of investigational product(s)
boolean
C2349954 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Concomitant medication
Item
Concomitant medication (record in Section 8)
boolean
C2347852 (UMLS CUI [1])
Activity related to study participation
Item
Activity related to study participation (e.g., procedures)
boolean
Other cause of SAE
Item
Other
boolean
C0205394 (UMLS CUI [1])
Other cause of SAE specification
Item
Other, specify
text
C1707811 (UMLS CUI [1,1])
C3840932 (UMLS CUI [1,2])
Item Group
Section 6: Relevant medical conditions
Medical conditions relevant to SAE
Item
Specify any RELEVANT past or current medical disorders, allergies, surgeries, etc. that can help explain the SAE
text
C0262926 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Date of onset
Item
Date of onset
date
C0574845 (UMLS CUI [1])
Condition Present at time of SAE
Item
Condition Present at Time of the SAE?
boolean
C0012634 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Date of Last Occurrence
Item
If No, Date of Last Occurrence
date
C2745955 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
C1519255 (UMLS CUI [1,4])
Item Group
Section 7
Other risk factors relevant to SAE
Item
Other RELEVANT Risk Factors (provide any family or social history (e.g., smoking, alcohol, diet, drug abuse, occupational hazard) relevant to the SAE)
integer
C0035648 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item Group
Section 8: RELEVANT Concomitant Medications (include details of any concomitant medication(s) which may have contributed to the event)
Drug name
Item
Drug name
text
C0013227 (UMLS CUI [1])
Dose
Item
Dose
float
C3174092 (UMLS CUI [1])
Unit
Item
Unit
text
C1519795 (UMLS CUI [1])
Frequency
Item
Frequency
float
C3476109 (UMLS CUI [1])
Route
Item
Route
integer
C0013153 (UMLS CUI [1])
medication taken prior to study
Item
Taken prior to study?
boolean
C2826667 (UMLS CUI [1])
Start date
Item
Start date
date
C0808070 (UMLS CUI [1])
Stop Date
Item
Stop Date
date
C0806020 (UMLS CUI [1])
Ongoing Medication
Item
Ongoing Medication?
boolean
C2826666 (UMLS CUI [1])
Reason for Medication
Item
Reason for Medication
integer
C0392360 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C2347852 (UMLS CUI [1,3])
Item Group
Section 9: Details of Investigational Product(s)
Dose level randomization
Item
Dose level randomization
integer
C0178602 (UMLS CUI [1,1])
C0034656 (UMLS CUI [1,2])
Start date randomization
Item
Start date (randomization)
date
C0034656 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Stop date randomization
Item
Stop date (randomization)
date
C0034656 (UMLS CUI [1,1])
C2598418 (UMLS CUI [1,2])
Continuation randomization
Item
Continuing (randomization)
boolean
C0034656 (UMLS CUI [1,1])
C1553904 (UMLS CUI [1,2])
Dose level At time of SAE
Item
Dose level At time of SAE
integer
C0178602 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Start date At time of SAE
Item
Start date (At time of SAE)
date
C1519255 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Stop date At time of SAE
Item
Stop date (At time of SAE)
date
C1519255 (UMLS CUI [1,1])
C2598418 (UMLS CUI [1,2])
Continuation At time of SAE
Item
Continuing (At time of SAE)
boolean
C1519255 (UMLS CUI [1,1])
C1553904 (UMLS CUI [1,2])
Item
Was randomisation code broken at investigational site?
text
C0034656 (UMLS CUI [1,1])
C3846431 (UMLS CUI [1,2])
randomisation code broken
Code List
Was randomisation code broken at investigational site?
CL Item
Yes (Yes)
C1705108 (UMLS CUI-1)
(Comment:en)
CL Item
No (No)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Not applicable (Not applicable)
C1272460 (UMLS CUI-1)
(Comment:en)
Item Group
Section 10
Details of relevant assessments
Item
Details of RELEVANT Assessments (provide details of any other tests/procedures which were carried out to diagnose or confirm the SAE e.g., laboratory data with units and normal range)
text
C1261322 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item Group
Section 11
Narrative Remarks
Item
Narrative Remarks (provide a brief narrative description of the SAE and details of treatment given)
text
C0947611 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
Item Group
Investigator information
Investigator’s signature
Item
Investigator’s signature
text
C2346576 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Investigator’s name
Item
Investigator’s name
text
C2826892 (UMLS CUI [1])
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