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This is an example CRF of Protocol deviations. The CRF has two section. Section 1 collects whether the the subject had any protocol deviations. The second section creates a row/record for every deviation each subject experiienced. 

Section 1 

OrderQuestion TextPromptCase Report Form Completion InstructionsTypeCollection VariableTabulation Target  Mapping Instructions  Controlled Terminology CodeList NamePermissible ValuesPre-Populated Value
1Were there any protocol deviations?Any DeviationsEnter Yes if a protocol deviation occurred and No if none occurred. Ensure that any adverse event which triggers a protocol deviation (e.g., concomitant medication use, newly discovered medical history) is noted on the respective CRF.TextDVYNNot Submitted(NY)Yes; No

Section 2 
OrderQuestion TextPromptCase Report Form Completion InstructionsTypeCollection VariableTabulation Target  Mapping Instructions  Controlled Terminology CodeList NamePermissible ValuesPre-Populated Value
2What is the protocol deviation identifier?DV NumberIf collected on the CRF, applicant may insert instructions to ensure each record has a unique identifier.TextDVSPIDDVSPID



3What was the protocol deviation?Protocol DeviationRecord protocol deviations identified and/or select the appropriate code from the list of protocol deviation terms.TextDVDECODDVDECOD
INFORMED CONSENT NOT OBTAINED; INCLUSION CRITERIA NOT MET; STUDY PRODUCT ASSIGNMENT DEVIATION; STUDY PRODUCT ADMINSTRATION DEVIATION; EXCLUDED CONCOMITANT MEDICATION; OTHER

4What was the protocol deviation term?Specify Protocol DeviationRecord the protocol deviation TextDVTERMDVTERM



5What was the protocol deviation start date?Start DateRecord the start date for the protocol deviation using this format (DD-MON-YYYY). This should be the start or occurrence of the protocol deviation, not the date it was discovered or reported.DateDVSTDTCDVSTDTC



6What was the protocol deviation end date?End DateRecord the end date of the protocol deviation using this format (DD-MON-YYYY). This should be the date the protocol deviation stopped, not the date it was discovered or reported.DateDVENDTCDVENDTC



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