This form collects events and malfunctions associated with the operation of the tobacco product device.

Section 1 

OrderQuestion TextPromptCase Report Form Completion InstructionsTypeCollection VariableTabulation Target  Mapping Instructions Controlled Terminology CodeList NamePermissible ValuesPre-Populated Value
1Any Tobacco Product EventsAny Tobacco Product EventsIndicate if the subject experienced any medical conditions or events. If Yes, include the appropriate details where indicated on the CRF.TextEMYNEMYNN/A(NY)No;Yes
2Tobacco Product Identifier Tobacco Product Identifier Indicate the  product that  was associated with the event. TextSPTOBIDSPTOBID


VAPE-Z01

Section 2 

OrderQuestion TextPromptCase Report Form Completion InstructionsTypeCollection VariableTabulation Target  Mapping Instructions Controlled Terminology CodeList NamePermissible ValuesPre-Populated Value
3

What was the event or malfunction associated with this device?

Tobacco Product Device EventRecord a description of the toboacco product device event or malfunction that occurred.TextEMTERMEMTERM



4What was the start date when the event or malfunction first occurred or was identified?Start DateRecord the date that the event or malfunction first occurred or was noted using this format (DD-MON-YYYY).DateEMSTDATEMSTDTC



5What was the pattern of the event of malfunction?Pattern of Tobacco Product Device EventRecord the pattern of the the event or malfunction that occurred.TextEMPATTEMPATT

Single Event; Intermittent; Continuous
6What action was taken with the device?Action Taken With DeviceRecord what action was taken with the device as a result of the event.TextEMACNDEVEMACNDEV
(DEACNDEV)

No Action Taken; Device Replaced; Battery Replaced


7What was the identifier for the primary adverse event(s) associated with or related to this device event?Related Adverse Event IDRecord the ID of the primary AE associated with event, if any.TextEMAENO(n)N/AASSOCIATE WITH RELATED RECORD VIA RELREC