CDASH Ryze Example.Adverse Experiences

This is an example CRF used to collect general adverse experiences. This CRF was designed to allow the applicant to use either AEENRF or AEENRTPT to represent an event was ongoing. This form has 2 sections. Section one collects whether a subject expeiences any adverse events, while Section 2 collects a record/row for each adverse experience. Section 1

Section 2

This is the metadata specifications for section 1 of the CRF.

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
1	Were there any adverse experiences?	Any Adverse Experiences	Indicate if the subject experienced any adverse experiences. If Yes, include the appropriate details where indicated on the CRF.	Text	AEYN	N/A		(NY)	Yes; No

THis is the metadata specifications for Section 2 of the CRF.

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
2	What is the category of the adverse experience?	Adverse Experiences Category	Record the adverse experience category, if not pre-printed on the CRF.	Text	AECAT	AECAT				Applicant Defined
3	What is the subcategory of the adverse experience?	Adverse Experience Subcategory	Record the adverse experience subcategory, if not pre-printed on the CRF.	Text	AESCAT	AESCAT				Applicant Defined
4	What is the adverse experience identifier?	AE Number	If collected on the CRF, the applicant may insert instructions to ensure each record has a unique identifier.	Integer	AESPID	AESPID
5	What is the adverse experience term?	Adverse Experiences	Record only 1 diagnosis, sign, or symptom per line (e.g., nausea and vomiting should not be recorded in the same entry, but as 2 separate entries). Using accepted medical terminology, enter the diagnosis (if known); otherwise, enter a sign or symptom.	Text	AETERM	AETERM
6	What is the adverse experience start date?	Start Date	Record the start date of the AE using this format (DD-MON-YYYY).	Date	AESTDAT	AESTDTC
7	Is the adverse experience ongoing?	Ongoing	Indicate if the adverse experience has not resolved at the time of data collection; leave the End Date blank.	Text	AEONGO	AEENRTPT; AEENRF	AEENRTPT/ AEENRF	(NY)	Yes
8	What was the adverse experience end date?	End Date	Record the date that the AE resolved using this format (DD-MON-YYYY). If the AE is ongoing, leave the field blank.	date	AEENDAT	AEENDTC
9	What is the severity of the adverse experience?	Severity	The reporting physician/healthcare professional will assess the severity of the experience using applicant-defined categories. This assessment is subjective, and the reporting physician/healthcare professional should use medical judgment to compare the reported AE to similar type experiences observed in clinical practice. Severity is not equivalent to seriousness.	Text	AESEV	AESEV		(AESEV)	MILD; MODERATE; SEVERE
10	Was the adverse experience serious?	Serious	Assess if an adverse experience should be classified as serious based on the criteria defined in the protocol.	Text	AESER	AESER		(NY)	Yes; No
11	Did the adverse experience result in death?	Death	Record whether the serious adverse experience resulted in death.	Text	AESDTH	AESDTH		(NY)	Yes; No
12	What[was the subject’s date of death?	Death Date	Record the date of death.	date	DTHDAT	DM.DTHDTC
13	Was the adverse experience life-threatening?	Life Threatening	Record whether the serious adverse experience is life-threatening.	Text	AESLIFE	AESLIFE		(NY)	Yes; No
14	Did the adverse experience result in initial or prolonged hospitalization for the subject?	Hospitalization (initial or prolonged)	Record whether the serious adverse experience resulted in an initial or prolonged hospitalization.	Text	AESHOSP	AESHOSP		(NY)	Yes; No
15	Did the adverse experience result in disability or permanent damage?	Disability or Permanent Damage	Record whether the serious adverse experience resulted in a persistent or significant disability or incapacity.	Text	AESDISAB	AESDISAB		(NY)	Yes; No
16	Was the adverse experience associated with a congenital anomaly or birth defect?	Congenital Anomaly or Birth Defect	Record whether the serious adverse experience was associated with congenital anomaly or birth defect.	Text	AESCONG	AESCONG		(NY)	Yes; No
17	Did the adverse experience require intervention to prevent permanent impairment or damage resulting from the use of a medical product?	Needs Intervention to Prevent Impairment	Record whether the serious adverse experience required intervention to prevent permanent impairment or damage due to the use of a medical product.	Text	AESINTV	SUPPAE.QVAL		(NY)	Yes; No
18	Was the adverse experience a medically important event not covered by other "serious" criteria?	Other Serious (Important Medical Events)	Record whether the serious adverse experience is an important medical event, which may be defined in the protocol or in the investigator brochure.	Text	AESMIE	AESMIE		(NY)	Yes; No
19	Was this adverse experience related to study product?	Relationship to Study Product	Indicate if the cause of the adverse experience was related to the study product and cannot be reasonably explained by other factors (e.g., subject's clinical state, concomitant therapy, other interventions).	Text	AEREL	AEREL			NOT RELATED; UNLIKELY RELATED; POSSIBLY RELATED; RELATED
20	What action was taken with the study product?	Action Taken with Study Product	Record changes made to the study intervention resulting from the adverse experience.	Text	AEACN	AEACN		(ACN)	DRUG WITHDRAWN; DOSE REDUCED; DOSE INCREASED; DOSE NOT CHANGED; UNKNOWN; NOT APPLICABLE
21	What is the outcome of this adverse experience?	Outcome	Record the appropriate outcome of the experience in relation to the subject's status.	Text	AEOUT	AEOUT		(OUT)	RECOVERING / RESOLVING; NOT RECOVERED / NOT RESOLVED; RECOVERED / RESOLVED; RECOVERED / RESOLVED WITH SEQUELAE; FATAL
22	What is the action taken with a device?	Action Taken with Device	Record any action taken with a device as the result of the adverse experience. The device may or may not be a device under study.	Text	AEACNDEV	AEACNDEV		(DEACNDEV)	CALIBRATION; REMOVAL; REPROGRAMMING
23	Was this adverse experience related to a device?	Relationship of Experience to Device	Record the relationship of the adverse experience to Device	Text	AERLDEV	AERLDEV			NOT RELATED; UNLIKELY RELATED; POSSIBLY RELATED; RELATED

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CDASH Ryze Example.Adverse Experiences