| Order | Question Text | Prompt | Case Report Form Completion Instructions | Type | Collection Variable | Tabulation Target | Mapping Instructions | Controlled Terminology CodeList Name | Permissible Values | Pre-Populated Value |
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| 1 | Was the ECG performed? | ECG Performed | Indicate whether or not an ECG or specific ECG test was done. | Text | EGSTAT | EGSTAT |
| (NY) | NON;YESY |
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| 2 | What was the method used for the ECG? | Method | Record the method used for the ECG. | Text | EGMETHOD | EGMETHOD |
| (EGMETHOD) | 12 LEAD STANDARD;HOLTER CONTINUOUS ECG RECORDING |
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| 3 | What was the position of the subject during the ECG measurement? | Position | Record the position of the subject during the ECG. | Text | EGPOS | EGPOS |
| (POSITION) | SITTING;STANDING;SUPINE;SEMI-RECUMBENT;SEMI-FOWLERS |
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| 4 | What was date of the ECG? | ECG Date | Record the date ECG was done using this format. | Date | EGDTC | EGDTC |
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| 5 | What was the Mean Heart Rate? | ECG Mean Heart Rate | Record the test result. | Integer | EGHRMN_EGORRES | EGORRES | EGORRES where EGTESTCD ="EGHRMN" |
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| 6 | What was the unit of the Mean Heart Rate? | Unit | Record or select the original unit in which these data were collected, if not pre-printed on CRF. | Text | EGHRMN_EGORRESU | EGORRESU | EGORRESU where EGTESTCD = "EGHRMN" | (Unit) | beats/min |
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| 7 | What was the Aggregate PR Interval? | PR Interval, Aggregate | Record the test result. | Integer | PRAG_EGORRES | EGORRES | EGORRES where EGTESTCD = "PRAG" |
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| 8 | What was the unit of the Aggregate PR Interval? | Unit | Record or select the original unit in which these data were collected, if not pre-printed on CRF. | Text | PRAG_EGORRESU | EGORRESU | EGORRESU where EGTESTCD = "PRAG" | (Unit) | msecs |
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| 9 | What was the Aggregate QRS Duration? | QRS Duration, Aggregate | Record the test result. | Integer | QRSAG_EGORRES | EGORRES | EGORRES where EGTESTCD = "QRSAG" |
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| 10 | What was the unit of the Aggregate QRS Duration? | Unit | Record or select the original unit in which these data were collected, if not pre-printed on CRF. | Text | QRSAG_EGORRESU | EGORRESU | EGORRESU where EGTESTCD = "QRSAG" | (Unit) | msecs |
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| 11 | What was the Aggregate QT Interval? | QT Interval, Aggregate | Record the test result. | Integer | QTAG_EGORRES | EGORRES | EGORRES where EGTESTCD = "QTAG" |
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| 12 | What was the unit of the Aggregate QT Interval result? | Unit | Record or select the original unit in which these data were collected, if not pre-printed on CRF. | Text | QTAG_EGORRESU | EGORRESU | EGORRESU where EGTESTCD = "QTAG" | (Unit) | msecs |
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| 13 | What was the Aggregate QTca Interval? | QTca Interval, Aggregate | Record the test result. | Integer | QTCAAG_EGORRES | EGORRES | EGORRES where EGTESTCD = "QTCA" |
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| 14 | What was the unit of the Aggregate QTca Interval? | Unit | Record or select the original unit in which these data were collected, if not pre-printed on CRF. | Text | QTCAAG_EGORRESU | EGORRESU | EGORRESU where EGTESTCD = "QTCA" | (Unit) | msecs |
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| 15 | What was the overall interpretation of the ECG? | Interpretation | Record the the test result. | Text | INTP_EGORRES | EGORRES | EGORRES where EGTESTCD = "INTP" | (NORMABNM) | NORMAL; ABNORMAL |
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| 16 | Was the ECG clinically significant? | Clinically Significant | Record whether ECG results were clinically significant. | Text | EGCLSIG | EGCLSIG |
| (NY) | Y N:NY: |
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