Centre number
Item
Centre number
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Gender
text
C0079399 (UMLS CUI [1])
Item
Race
integer
C0034510 (UMLS CUI [1])
CL Item
Arabic/North African (4)
CL Item
White/Caucasian (2)
CL Item
East & South East Asian (5)
CL Item
American Hispanic (7)
CL Item
Other, please specify (9)
If other race, please specify
Item
If other race, please specify
text
C0034510 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study?
Item
Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study?
boolean
C0521987 (UMLS CUI [1])
C0037088 (UMLS CUI [2,1])
C2347804 (UMLS CUI [2,2])
C0332152 (UMLS CUI [2,3])
Has a blood sample been taken for testing anti-HAV and anti-HBs antibodies?
Item
Has a blood sample been taken for testing anti-HAV and anti-HBs antibodies?
boolean
C0005834 (UMLS CUI [1,1])
C0201473 (UMLS CUI [1,2])
C0005834 (UMLS CUI [2,1])
C0201478 (UMLS CUI [2,2])
Date of Blood sample been taken
Item
Date of Blood sample been taken
date
C1277698 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Has the subject received since the last visit - 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 [1,1])
C0545082 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
C1711239 (UMLS CUI [1,4])
C2240392 (UMLS CUI [2,1])
C0545082 (UMLS CUI [2,2])
C1517741 (UMLS CUI [2,3])
C1711239 (UMLS CUI [2,4])
Item
If subject has recieved a dose of monovalent or combined Hepatitis A or Hepatitis B vaccine, please specify
integer
C0170300 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
C2240392 (UMLS CUI [2,1])
C2348235 (UMLS CUI [2,2])
Code List
If subject has recieved a dose of monovalent or combined Hepatitis A or Hepatitis B vaccine, please specify
CL Item
Hepatitis A vaccine (1)
CL Item
Hepatitis B vaccine (2)
CL Item
Combined Hepatitis A and B vaccine (3)
Has the subject received since the last visit - A dose of Hepatitis A or Hepatitis B immunoglobulins within 6 months prior to bleeding?
Item
Has the subject received since the last visit - A dose of Hepatitis A or Hepatitis B immunoglobulins within 6 months prior to bleeding?
boolean
C3652495 (UMLS CUI [1,1])
C0019080 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
C0062525 (UMLS CUI [2,1])
C0019080 (UMLS CUI [2,2])
C0332152 (UMLS CUI [2,3])
Item
If subject has received a dose of Hepatitis A or Hepatitis B immunoglobulins within 6 months prior to bleeding, please specify.
integer
C3652495 (UMLS CUI [1,1])
C0019080 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
C0062525 (UMLS CUI [2,1])
C0019080 (UMLS CUI [2,2])
C0332152 (UMLS CUI [2,3])
C2348235 (UMLS CUI [2,4])
Code List
If subject has received a dose of Hepatitis A or Hepatitis B immunoglobulins within 6 months prior to bleeding, please specify.
CL Item
Hepatitis A immunoglobulins (1)
CL Item
Hepatitis B immunoglobulins (2)
Has an additional blood sample been taken prior to additional vaccine dose?
Item
Has an additional blood sample been taken prior to additional vaccine dose?
boolean
C0005834 (UMLS CUI [1,1])
C1524062 (UMLS CUI [1,2])
C0042210 (UMLS CUI [2,1])
C0178602 (UMLS CUI [2,2])
C1524062 (UMLS CUI [2,3])
Additional blood sample Date
Item
Additional blood sample Date
date
C0005834 (UMLS CUI [1,1])
C1524062 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
Has a urine sample been taken ?
integer
C0430056 (UMLS CUI [1])
Code List
Has a urine sample been taken ?
CL Item
NA (not of childbearing potential or male) (3)
Date of urine sample been taken
Item
Date of urine sample been taken
date
C0430056 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Result
integer
C1274040 (UMLS CUI [1])
Has the patient became seronegative for anti-HAV antibodies (i.e. titres < 15 mIU/ml)
Item
Has the patient became seronegative for anti-HAV antibodies (i.e. titres < 15 mIU/ml)
boolean
C0521144 (UMLS CUI [1,1])
C0062524 (UMLS CUI [1,2])
C0475208 (UMLS CUI [2])
Has the patient lost seroprotective titres for anti-HBs antibodies (i.e. titres < 10 mIU/ml)
Item
Has the patient lost seroprotective titres for anti-HBs antibodies (i.e. titres < 10 mIU/ml)
text
C0521144 (UMLS CUI [1,1])
C0201478 (UMLS CUI [1,2])
C0475208 (UMLS CUI [2])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Pre-Vaccination temperature
Item
Pre-Vaccination temperature
float
C0005903 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0332152 (UMLS CUI [1,3])
Item
Temperature Route
text
C0005903 (UMLS CUI [1,1])
C0449687 (UMLS CUI [1,2])
Code List
Temperature Route
Item
Vaccine Administration
integer
C2368628 (UMLS CUI [1])
Code List
Vaccine Administration
CL Item
Twinrix™ Adult (720/20) Vaccine (1)
CL Item
Twinrix™ Adult (720/20) Vaccine - Replacement vial (2)
CL Item
Twinrix™ Adult (720/20) Vaccine - Wrong vial number (3)
CL Item
Twinrix™ Adult (720/20) Vaccine not administered (4)
CL Item
Engerix™ (20 µg) Vaccine (5)
CL Item
Engerix™ (20 µg) Vaccine - Replacement vial (6)
CL Item
Engerix™ (20 µg) Vaccine - Wrong vial number (7)
CL Item
Engerix™ (20 µg) Vaccine not administered (8)
CL Item
Havrix™ (720 EL.U) Vaccine (9)
CL Item
Havrix™ (720 EL.U) Vaccine - Replacement vial (10)
CL Item
Havrix™ (720 EL.U) Vaccine - Wrong vial number (11)
CL Item
Havrix™ (720 EL.U)Vaccine not administered (12)
Item
Replacement vial
integer
C0184301 (UMLS CUI [1,1])
C0559956 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Code List
Replacement vial
Wrong vial number
Item
Wrong vial number
integer
C0184301 (UMLS CUI [1])
Item
Side/ Site Route
integer
C2368628 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
C0013153 (UMLS CUI [1,3])
C0441987 (UMLS CUI [1,4])
Code List
Side/ Site Route
CL Item
Non dominant Deltoid i.m. (1)
Has the study vaccine been administered according to the Protocol?
Item
Has the study vaccine been administered according to the Protocol?
boolean
C2368628 (UMLS CUI [1,1])
C2348563 (UMLS CUI [1,2])
Item
If study vaccine has not been administered according to the Protocol, please tick all items that apply
integer
C2368628 (UMLS CUI [1,1])
C2348563 (UMLS CUI [1,2])
Code List
If study vaccine has not been administered according to the Protocol, please tick all items that apply
Comments
Item
Comments
text
C0947611 (UMLS CUI [1])
Item
Why not administered?
text
C2368628 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C1272696 (UMLS CUI [1,3])
Code List
Why not administered?
CL Item
Serious adverse event (complete the Serious Adverse Event form) (SAE)
CL Item
Non-Serious adverse event (complete the Non-serious Adverse Event section) (AEX)
CL Item
Other, please specify (e.g.: consent withdrawal, protocol violation, …) (OTH)
If not administered because of SAE, please specify SAE No.
Item
If not administered because of SAE, please specify SAE No.
integer
C2368628 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C1272696 (UMLS CUI [1,3])
C1519255 (UMLS CUI [2,1])
C0237753 (UMLS CUI [2,2])
If not administered because of Non-serious Adverse Event, please specify unsolicited or solicited AE No.
Item
If not administered because of Non-serious Adverse Event, please specify unsolicited or solicited AE No.
integer
C2368628 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C1272696 (UMLS CUI [1,3])
C1518404 (UMLS CUI [2,1])
C0237753 (UMLS CUI [2,2])
If other reason for non administration, please specify
Item
If other reason for non administration, please specify
text
C1533734 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C1272696 (UMLS CUI [1,3])
C0205394 (UMLS CUI [1,4])
C2348235 (UMLS CUI [1,5])
Item
Please tick who took the decision
text
C0679006 (UMLS CUI [1])
Code List
Please tick who took the decision
CL Item
Parents/ Guardians (P)
Item
Has the subject experienced any serious or non-serious unsolicited adverse events during the 30-day (Day 0 to Day 29) post-vaccination?
text
C1519255 (UMLS CUI [1,1])
C0687676 (UMLS CUI [1,2])
C0042196 (UMLS CUI [1,3])
C0877248 (UMLS CUI [2,1])
C0687676 (UMLS CUI [2,2])
C0042196 (UMLS CUI [2,3])
Code List
Has the subject experienced any serious or non-serious unsolicited adverse events during the 30-day (Day 0 to Day 29) post-vaccination?
CL Item
Information not available (U)
CL Item
No Vaccine administered (NA)
CL Item
Yes, fill in the Non-Serious Adverse Event pages or Serious Adverse Event form. (Y)
Item
Has the subject experienced any of the following signs/symptoms at the administration site during the solicited period?
text
C0037088 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
C0013153 (UMLS CUI [1,3])
Code List
Has the subject experienced any of the following signs/symptoms at the administration site during the solicited period?
CL Item
Information not available (U)
CL Item
No Vaccine administered (NA)
CL Item
Yes, please tick No/Yes for each symptom. If Yes is ticked, please complete all items (Y)
Redness
Item
Redness
boolean
C0332575 (UMLS CUI [1])
Redness size Day 0
Item
Redness size Day 0
integer
C0456389 (UMLS CUI [1,1])
C0332575 (UMLS CUI [1,2])
Redness size Day 1
Item
Redness size Day 1
integer
C0456389 (UMLS CUI [1,1])
C0332575 (UMLS CUI [1,2])
Redness size Day 2
Item
Redness size Day 2
integer
C0456389 (UMLS CUI [1,1])
C0332575 (UMLS CUI [1,2])
Redness size Day 3
Item
Redness size Day 3
integer
C0456389 (UMLS CUI [1,1])
C0332575 (UMLS CUI [1,2])
Redness Ongoing after Day 3?
Item
Redness Ongoing after Day 3?
boolean
C0332575 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
If Redness is ongoing, record date of last Day of Symptoms
Item
If Redness is ongoing, record date of last Day of Symptoms
date
C0332575 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C1517741 (UMLS CUI [2,2])
C1457887 (UMLS CUI [2,3])
Swelling
Item
Swelling
boolean
C0038999 (UMLS CUI [1])
Swelling Size Day 0
Item
Swelling Size Day 0
integer
C0038999 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
Swelling Size Day 1
Item
Swelling Size Day 1
integer
C0038999 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
Swelling Size Day 2
Item
Swelling Size Day 2
integer
C0038999 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
Swelling Size Day 3
Item
Swelling Size Day 3
integer
C0038999 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
Swelling Ongoing after Day 3?
Item
Swelling Ongoing after Day 3? +
boolean
C0038999 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
If Swelling is ongoing, record date of last Day of Symptoms
Item
If Swelling is ongoing, record date of last Day of Symptoms
date
C0038999 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C1517741 (UMLS CUI [2,2])
C1457887 (UMLS CUI [2,3])
Pain
Item
Pain
boolean
C0030193 (UMLS CUI [1])
Item
Pain intensity Day 0
integer
C1320357 (UMLS CUI [1])
Code List
Pain intensity Day 0
Item
Pain intensity Day 1
integer
C1320357 (UMLS CUI [1])
Code List
Pain intensity Day 1
Item
Pain intensity Day 2
integer
C1320357 (UMLS CUI [1])
Code List
Pain intensity Day 2
Item
Pain intensity Day 3
integer
C1320357 (UMLS CUI [1])
Code List
Pain intensity Day 3
Pain Ongoing after Day 3?
Item
Pain Ongoing after Day 3?
boolean
C0030193 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
If Pain is ongoing, record date of last Day of Symptoms
Item
If Pain is ongoing, record date of last Day of Symptoms
date
C0030193 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C1517741 (UMLS CUI [2,2])
C1457887 (UMLS CUI [2,3])
Item
Has the subject experienced any of the following signs/symptoms during the solicited period?
text
C0037088 (UMLS CUI [1])
Code List
Has the subject experienced any of the following signs/symptoms during the solicited period?
CL Item
Information not available (U)
CL Item
No Vaccine administered (NA)
CL Item
Yes, please tick No/Yes for each symptom. If Yes is ticked, please complete all items. (Y)
Fever
Item
Fever
boolean
C0015967 (UMLS CUI [1])
Item
Temperature Route
text
C0005903 (UMLS CUI [1,1])
C0449687 (UMLS CUI [1,2])
Code List
Temperature Route
Temperature Day 0
Item
Temperature Day 0
float
C0005903 (UMLS CUI [1])
Item
Temperature not taken Day 0
integer
C0437722 (UMLS CUI [1])
Code List
Temperature not taken Day 0
Temperature Day 1
Item
Temperature Day 1
float
C0005903 (UMLS CUI [1])
Item
Temperature not taken Day 1
integer
C0437722 (UMLS CUI [1])
Code List
Temperature not taken Day 1
Temperature Day 2
Item
Temperature Day 2
float
C0005903 (UMLS CUI [1])
Item
Temperature not taken Day 2
integer
C0437722 (UMLS CUI [1])
Code List
Temperature not taken Day 2
Temperature Day 3
Item
Temperature Day 3
float
C0005903 (UMLS CUI [1])
Item
Temperature not taken Day 3
integer
C0437722 (UMLS CUI [1])
Code List
Temperature not taken Day 3
Fever ongoing after Day 3?
Item
Fever ongoing after Day 3?
boolean
C0015967 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
If Fever is ongoing, record date of last Day of Symptoms
Item
If Fever is ongoing, record date of last Day of Symptoms
date
C0015967 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C1517741 (UMLS CUI [2,2])
C1457887 (UMLS CUI [2,3])
Fever - Causality?
Item
Fever - Causality?
boolean
C0015967 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
Fatigue
Item
Fatigue
boolean
C0015672 (UMLS CUI [1])
Item
Fatigue intensity Day 0
integer
C0015672 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Fatigue intensity Day 0
Item
Fatigue intensity Day 1
integer
C0015672 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Fatigue intensity Day 1
Item
Fatigue intensity Day 2
integer
C0015672 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Fatigue intensity Day 2
Item
Fatigue intensity Day 3
integer
C0015672 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Fatigue intensity Day 3
Fatigue ongoing after Day 3?
Item
Fatigue ongoing after Day 3?
boolean
C0015672 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
If Fatigue is ongoing, record date of last Day of Symptoms
Item
If Fatigue is ongoing, record date of last Day of Symptoms
date
C0015672 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C1517741 (UMLS CUI [2,2])
C1457887 (UMLS CUI [2,3])
Fatigue - Causality?
Item
Fatigue - Causality?
boolean
C0015672 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
Headache
Item
Headache
boolean
C0018681 (UMLS CUI [1])
Item
Headache intensity Day 0
integer
C0018681 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Headache intensity Day 0
Item
Headache intensity Day 1
integer
C0018681 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Headache intensity Day 1
Item
Headache intensity Day 2
integer
C0018681 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Headache intensity Day 2
Item
Headache intensity Day 3
integer
C0018681 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Headache intensity Day 3
Headache ongoing after Day 3?
Item
Headache ongoing after Day 3?
boolean
C0018681 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
If Headache is ongoing, record date of last Day of Symptoms
Item
If Headache is ongoing, record date of last Day of Symptoms
date
C0018681 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C1517741 (UMLS CUI [2,2])
C1457887 (UMLS CUI [2,3])
Headache - Causality?
Item
Headache - Causality?
boolean
C0018681 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
Gastrointestinal symptoms
Item
Gastrointestinal symptoms
boolean
C0426576 (UMLS CUI [1])
Item
Gastrointestinal symptoms intensity Day 0
integer
C0426576 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Gastrointestinal symptoms intensity Day 0
Item
Gastrointestinal symptoms intensity Day 1
integer
C0426576 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Gastrointestinal symptoms intensity Day 1
Item
Gastrointestinal symptoms intensity Day 2
integer
C0426576 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Gastrointestinal symptoms intensity Day 2
Item
Gastrointestinal symptoms intensity Day 3
integer
C0426576 (UMLS CUI [1,1])
C0518690 (UMLS CUI [1,2])
Code List
Gastrointestinal symptoms intensity Day 3
Gastrointestinal Symptoms ongoing after Day 3?
Item
Gastrointestinal Symptoms ongoing after Day 3?
boolean
C0426576 (UMLS CUI [1,1])
C3174772 (UMLS CUI [1,2])
If Gastrointestinal symptoms are ongoing, record date of last Day of Symptoms
Item
If Gastrointestinal symptoms are ongoing, record date of last Day of Symptoms
date
C0426576 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C1517741 (UMLS CUI [2,2])
C1457887 (UMLS CUI [2,3])
Gastrointestinal Symptoms - Causality?
Item
Gastrointestinal Symptoms - Causality?
boolean
C0426576 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])