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There are 2 sections in this example. The questions in the first section focus whether subject characteristics were collected and the questions in the second section are each subject characteristic collected. For an eCRF, if "No" is selected as the answer to the question in the first section, the second section would not be displayed.

OrderCDASH Variable Name Question TextPromptCRF Completion InstructionsCDASH Variable Name SDTM VariableSDTM Target MappingControlled Terminology Code List NamePermissible ValuesPre-Populated Value
1SCPERFWere subject characteristics collected?Subject Characteristics CollectedIndicate if subject characteristics information was collected. If Yes, record the appropriate details.SCPERFSCSTATIf SCPERF = "Y", NOT SUBMITTED. If SCPERF = "N", SCSTAT where SCTESTCD = "SCALL".(NY)Yes; No
OrderCDASH Variable Name Question TextPromptCRF Completion InstructionsCDASH Variable Name SDTM VariableSDTM Target MappingControlled Terminology Code List NamePermissible ValuesPre-Populated Value
2EDLEVEL_SCORRESWhat is the subject's education level?Education LevelIndicate the subject's education level.EDLEVEL_SCORRESSCORRES;SCORRES WHERE SCTESTCD = "EDLEVEL"
Did not complete Secondary School or Less than High School; Some Secondary School or High School Education; High School or Secondary School Degree Complete; Associate’s or Technical Degree Complete; College or Baccalaureate Degree Complete; Doctoral or Postgraduate EducationLAST ATTEMPTED USE WITH THIS MEDICATION
3JOBCLAS_SCORRESWhat is the subject’s employment status?Employment StatusIndicate the subject's employment status.JOBCLAS_SCORRESSCORRESSCORRES WHERE SCTESTCD = "JOBCLAS"(EMPSTAT)Full-time; Part-time; Not employed
4INCOME_SCORRESWhat is the subject's income?Income Indicate the subject's  income.INCOME_SCORRESSCORRESSCORRES WHERE SCTESTCD = "INCOME"

<100% poverty guideline.;100-200% poverty guidelines; >200% poverty guidelines;


5MARISTAT_SCORRESWhat is the subject's marital status?Marital StatusIndicate the subject's marital status.MARISTAT_SCORRESSCORRESSCORRES WHERE SCTESTCD = "MARISTAT"(MARISTAT)Never Married; Married; Legally Separated; Divorced; Widowed
6NATORIG_SCORRESWhat is the subject's national origin status?National OriginIndicate the subject's national origin NATORIG_SCORRESSCORRESSCORRES WHERE SCTESTCD = "NATORIG"


7MILTSTAT_SCORRESWhat is the subject’s military status ?Military StatusIndicate the subject's military status.MILTSTAT_SCORRESSCORRESSCORRES WHERE SCTESTCD = "MILTSTAT"

NO MILITARY SEVICE;

ACTIVE SERVICE;

VETERAN;


8SECHNDTB_SCORRESWas the subject exposed  to second hand smoke ?Second Hand Smoke Exposure  Indicate the subject's exposure to second hand smoke SECHNDTB_SCORRESSCORRESSCORRES WHERE SCTESTCD = "SECHNDTB"

No Exposure to Second Hand smoke; 

Exposure at Home only; 

Exposure at work only; 

Exposure at Work and Home; 


9AGESTSMK__SCORRESWhat was the age of the subject when they started smoking?  Age Started SmokingRecord the Age Category when the subject started smokingAGESTSMK__SCORRESSCORRESSCORRES WHERE SCTESTCD = "AGESTSMK"
16-24 years; 25-34 years; 45–64 years; 65 years and older
10TBCESSCO__SCORRESDid the subject have any tobacco cessation counseling?Tobacco Cessation Counseling Indicate whether the subject had previous tobacco cessation counseling.TBCESSCO__SCORRESSCORRESSCORRES WHERE SCTESTCD = "TBCESSCO"(NY)Yes; No
11LDURABS__SCORRESWhat is the longest duration of previous abstinence from tobacco use? Longest Duration of  AbstinenceRecord the longest duration of tobacco abstinenceLDURABS__SCORRESSCORRESSCORRES WHERE SCTESTCD = "LDURABS"
≤7 days; 8–28 days;1–6 months;  >6 months 

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