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 This CRF collects medications used for nicotine dependency. 

OrderQuestion TextPromptCRF Completion InstructionsCDASH Variable Name SDTMIG Target VariableSDTM Target MappingControlled Terminology Code List NamePermissible ValuesPre-Populated Value
1What was the medication name? Medication
CMTRTCMCAT

NICOTINE REPLACEMENT THERAPY: DRUG USED IN REDUCING NICOTINE DEPENDENCE OTHER THAN NRTS  



2
Pre-Specified Intervention
CMPRESPCMSCAT


LAST ATTEMPTED USE WITH THIS MEDICATION
3Did the subject previously use medications to reduce nicotine dependency?Any Medications Taken For Nicotine DependencyIndicate if the subject had used any medically acceptable products to attempt to reduce nicotine dependencyCMOCCURCMTRT



4How many times did the subject attempt to use a medication to reduce nicotine dependency.Times the Subject Attempted to Reduce Nicotine DependencyRecord the number of times a subject attempted to use a medication to reduce nicotine dependencyFAORRESCMDUR



5What is the category of the medication the subject used to attempt to reduce nicotine dependency? Medication CategoryRecord the type of medication the subject used to reduce nicotine dependency.FACATCMDUR

DAYS; MONTHS; YEARS
6What is the category of the medication the subject used to attempt to reduce nicotine dependency? Medication CategoryRecord the type of medication the subject used to reduce nicotine dependency.CMCATCMCAT

NICOTINE REPLACEMENT THERAPY; DRUG USED IN REDUCING NICOTINE DEPENDENCE OTHER THAN NRTS;  



7What is the subcategory for the medication?Medication SubcategoryRecord the medication subcategory, if not pre-printed on the CRF.CMSCATCMSCAT


LAST ATTEMPTED USE WITH THIS MEDICATION
8What was the name of the medication the subject used to reduce nicotine dependency? 

 MedicationRecord only one medication per line. Provide the full trade or proprietary name of the medication; otherwise, record the generic name.CMTRTCMTRT



9What was the duration of the medication used to reduce nicotine dependency for the last attempt?  Collected DurationProvide the duration of the medication used. CMCDURCMDUR



10What was the duration unit of the medication used to reduce nicotine dependency for the last attempt?   Collected Duration UnitSelect the appropriate duration unit of the medication used. CMCDURUCMDUR

DAYS; MONTHS; YEARS

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