Example Case Report Forms for DS domain
Sources: DB1 | Forms loaded: 5
Form: Consent Withdrawls
Show domain info
Primary Domain
DS
All Domains
DS
# Question Response
1
Type of Consent
field_001
2
Date of Consent Withdrawal
field_002
Example Case Report Forms for DS domain
Sources: DB1 | Forms loaded: 5
Form: Screen Fail Status
Show domain info
Primary Domain
DS
All Domains
DS
# Question Response
1
Is the subject a screen fa
field_001
2
Primary Screen Failure Rea
field_002
3
If Primary Screen Failure
field_003
4
field_004
Example Case Report Forms for DS domain
Sources: DB1 | Forms loaded: 5
Form: Enrollment
Show domain info
Primary Domain
DM
All Domains
DM, DS
# Question Response
1
Date Consent Form Signed
enrlment.ICDT_RAW
2
Consent Version Number
enrlment.ICVERS
3
Protocol Version
enrlment.PRTVERS
4
Date of Enrollment
enrlment.ENRLDT_RAW
5
Date of Randomization
enrlment.RANDDT_RAW
6
Randomization number
enrlment.RANDNO
Example Case Report Forms for DS domain
Sources: DB1 | Forms loaded: 5
Form: End of Treatment
Show domain info
Primary Domain
DS
All Domains
DS
# Question Response
1
Did the subject complete t
field_001
2
Did the subject complete t
field_002
3
Date of completion/discont
eos.EOSTDT_RAW
4
Primary reason for ending
eos.EOTERM
Example Case Report Forms for DS domain
Sources: DB1 | Forms loaded: 5
Form: End of Study
Show domain info
Primary Domain
DS
All Domains
DS
# Question Response
1
Did the subject complete t
field_001
2
Date of completion/discont
eos.EOSTDT_RAW
3
Primary reason for ending
eos.EOTERM
4
If other, specify
field_004