ࡱ> a bjbjzz ^P\P\& & f<TBT: J J 6PJPJPJ0222222$[V (LGz.J"Ll6M8V` 6kQQQnMR` 60Q(L0QQuJx` 0ĞKMX2v"0TvNDJxJx|x4PJLJ6QJ,J*PJPJPJVVOPJPJPJ(L(L(L(LPJPJPJPJPJPJPJPJPJ& > d: HEADER: PI NAME, Protocol or IRB Number, Protocol Short Title  Subject Initials Subject ID Date: / /  Month Day Year  Demographics  Subject UWHC Medical Record Number*: First Name*:Middle Name (or initial):Last Name*: Birthdate*: / / Month Day Year  Gender*: (check one)  FORMCHECKBOX  Male  FORMCHECKBOX  Female  FORMCHECKBOX  Unknown or Not Reported   Ethnicity*: (check one)  FORMCHECKBOX  Hispanic  FORMCHECKBOX  Non-Hispanic  FORMCHECKBOX  Unknown or Not Reported Race*: (check all that apply)  FORMCHECKBOX  American Indian or Alaska Native  FORMCHECKBOX  Asian  FORMCHECKBOX  Black or African American  FORMCHECKBOX  Native Hawaiian or Other Pacific Islander  FORMCHECKBOX  White or Caucasian  FORMCHECKBOX  Unknown or Not Reported  Other Medical Record Number(s): Medical Record NumberHospital/Care Provider (e.g. VA Hospital, Meriter Hospital, EPIC) Contact Information: Address:Unit #:City:State:Zip: Phone Number:  FORMCHECKBOX  Home  FORMCHECKBOX  Work  FORMCHECKBOX  Cell  FORMCHECKBOX  OtherAlternate Phone Number:  FORMCHECKBOX  Home  FORMCHECKBOX  Work  FORMCHECKBOX  Cell  FORMCHECKBOX  OtherEmail address: Preferred method of contact: Emergency Contact: Name:Address:Unit #:City:State:Zip: Phone Number:  FORMCHECKBOX  Home  FORMCHECKBOX  Work  FORMCHECKBOX  Cell  FORMCHECKBOX  OtherAlternate Phone Number:  FORMCHECKBOX  Home  FORMCHECKBOX  Work  FORMCHECKBOX  Cell  FORMCHECKBOX  OtherEmail address: Preferred method of contact: *indicates required field Form Completed By: Date:     PAGE  Form Number Version Date: 11/28/2016 HEADER: IRB Number, Title, PI Version Date:07/07/2009  Optional Investigator Identifier (CDASH Domain: Common) CDASH/SDTM Variable Name: INVID  Highly Recommended Protocol/Study Identifier (CDASH Domain: Common) CDASH/SDTM Variable Name: STUDYID  Highly Recommended Site No (If Applicable) (CDASH Domain: Common) CDASH/SDTM Variable Name: SITEID  Highly Recommended Subject Identifier (CDASH Domain: Common) CDASH/SDTM Variable Name: SUBJID This date format is not CDASH recommended. The CDASH-recommended date format is 2 numerical digits for the day, 3 digits for the month, 4 numerical digits for the year (e.g., 08-AUG-2008).  Optional Unique subject identifier (CDASH Domain: Common) CDASH/SDTM Variable Name: USUBJID This field may be removed if the study is not enrolling subjects with a UW Health MRN  Highly Recommended Birthdate (CDASH Domain: DM) CDASH Variable Name: BRTHDAT SDTM Variable Name: BRTHDTC  Highly Recommended Gender (CDASH Domain: DM) CDASH/SDTM Variable Name: SEX CDASH recommends the terminology SEX instead of GENDER  Recommended/Conditional Ethnicity (CDASH Domain: DM) CDASH/SDTM Variable Name: ETHNIC FDA Regulated Research Studies: The FDA has updated their guidance on collecting Race & Ethnicity data in clinical trials to allow for more detailed characterizations. For more information, please refer to the ICTR Knowledgebase:  Recommended/Conditional Race (CDASH Domain: DM) CDASH/SDTM Variable Name: RACE FDA Regulated Research Studies: The FDA has updated their guidance on collecting Race & Ethnicity data in clinical trials to allow for more detailed characterizations. 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