ࡱ> W Hbjbj,, yFaFag  ffBD N!4!!!h!"D!Aw*#B$(j$j$j$>>>vvvvvvv$x{v" ><="?@vffj$j$vNHNHNH$Afj$"j$vNH>vNHNHk6oj$\Adl"vw0Awm{|^B{|Doo{|@o>>NH>>>>>vv E.>>>Aw>>>>{|>>>>>>>>> B ,: HEADER: PI NAME, Protocol or IRB Number, Protocol Short Title  Subject Initials Subject ID Exam Date: / /  Month Day Year  Vital Sign Measurements (Standard)  FORMCHECKBOX  Vital Sign Measurements not performed Visit Number (check one):  FORMCHECKBOX  Visit #  FORMCHECKBOX  Visit #  FORMCHECKBOX  Visit #  FORMCHECKBOX  Visit #  FORMCHECKBOX  Visit #  FORMCHECKBOX  Visit # Height: inches Weight: lbs  FORMCHECKBOX  Height not measured  FORMCHECKBOX  Weight not measured  Time:  (using 24 hour format of hh:mm) Temperature: Fahrenheit   FORMCHECKBOX  Temperature not measured Method: (check one)  FORMCHECKBOX  Oral  FORMCHECKBOX  Axillary  FORMCHECKBOX  Tympanic  Respiratory Rate: breaths/min  FORMCHECKBOX  Respiratory Rate not measured  Heart Rate: beats/min  FORMCHECKBOX  Heart Rate not measured  Systolic Blood Pressure  mmHg  FORMCHECKBOX  Blood Pressure not measured Diastolic Blood Pressure mmHg Method: (check one)  FORMCHECKBOX  Manual  FORMCHECKBOX  Automated Location: (check one)  FORMCHECKBOX  Left Arm  FORMCHECKBOX  Right Arm Position: (check one)  FORMCHECKBOX  Sitting  FORMCHECKBOX  Supine  FORMCHECKBOX  Standing Additional Notes: Vital Sign Measurements obtained by:     Form Number Version Date: 12/22/2016 Page  PAGE 1 of  NUMPAGES 1 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  Recommended/Conditional Date of Measurement (CDASH Domain: VS) CDASH Variable Name: VSDAT SDTM Variable Name: VSDTC (ISO 8601 format) 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 Not performed (CDASH Domain: VS) CDASH Variable Name: VSPERF  Recommended/Conditional Planned Time Point (CDASH Domain: VS) CDASH Variable Name: VSTIM SDTM Variable Name: VSDTC (ISO 8601 format)  Highly Recommended Vitals Test Name (CDASH Domain: VS) CDASH/SDTM Variable Name: VSTEST  Recommended/Conditional Units (CDASH Domain: VS) CDASH/SDTM Variable Name: VSORRESU  Highly Recommended Vitals Test Name (CDASH Domain: VS) CDASH/SDTM Variable Name: VSTEST  Recommended/Conditional Units (CDASH Domain: VS) CDASH/SDTM Variable Name: VSORRESU  Optional Not performed (CDASH Domain: VS) CDASH Variable Name: VSPERF  Optional Not performed (CDASH Domain: VS) CDASH Variable Name: VSPERF  Recommended/Conditional Time of Measurement (CDASH Domain: VS) CDASH Variable Name: VSTIM SDTM Variable Name: VSDTC (ISO 8601 format)  Highly Recommended Vitals Test Name (CDASH Domain: VS) CDASH/SDTM Variable Name: VSTEST  Recommended/Conditional Units (CDASH Domain: VS) CDASH/SDTM Variable Name: VSORRESU  Optional Not performed (CDASH Domain: VS) CDASH Variable Name: VSPERF  Optional Location of measurment (CDASH Domain: VS) CDASH/SDTM Variable Name: VSLOC  Highly Recommended Vitals Test Name (CDASH Domain: VS) CDASH/SDTM Variable Name: VSTEST  Recommended/Conditional Units (CDASH Domain: VS) CDASH/SDTM Variable Name: VSORRESU  Optional (CDASH Domain: VS) CDASH Variable Name: VSPERF  Highly Recommended Vitals Test Name (CDASH Domain: VS) CDASH/SDTM Variable Name: VSTEST  Recommended/Conditional Units (CDASH Domain: VS) CDASH/SDTM Variable Name: VSORRESU  Optional Not performed (CDASH Domain: VS) CDASH Variable Name: VSPERF  Highly Recommended Vitals Test Name (CDASH Domain: VS) CDASH/SDTM Variable Name: VSTEST  Recommended/Conditional Units (CDASH Domain: VS) CDASH/SDTM Variable Name: VSORRESU  Optional Not performed (CDASH Domain: VS) CDASH Variable Name: VSPERF  Highly Recommended Vitals Test Name (CDASH Domain: VS) CDASH/SDTM Variable Name: VSTEST  Recommended/Conditional Units (CDASH Domain: VS) CDASH/SDTM Variable Name: VSORRESU  Optional Location of measurment (CDASH Domain: VS) CDASH/SDTM Variable Name: VSLOC  Recommended/Conditional Position of subject (CDASH Domain: VS) CDASH/SDTM Variable Name: VSPOS . . : . >?EFGHIKNlwxĵ{{յյndnSdSn hUhzCJ<OJQJ^JaJ<hzOJQJ^JhUhzOJQJ^J#huhz5CJOJQJ^JaJ&jhzOJQJU^JmHnHu&jh,OJQJU^JmHnHuhz5CJOJQJ^JaJ huhzCJOJQJ^JaJjhz0JUhzCJOJQJ^JaJ#h,hz6CJOJQJ^JaJGH A \ ] x |pkpppgd  [$\$gd [$\$^gdJ[U9$$d%d&d'd-DM NOPQ[$\$a$gd-6y$[$\$a$gdO[$\$^`gdz [$\$gdz $\$a$gdz     ǽǤteS<*#hUhJ[UCJOJQJ\^JaJ,jhUhJ[UCJOJQJU\^JaJ#h-6yh-6y5CJ OJQJ^JaJ hg;5CJ OJQJ^JaJ hYf5CJ OJQJ^JaJ h-6y5CJ OJQJ^JaJ #huh-6y5CJOJQJ^JaJ1jh-6y5CJ OJQJU^JaJ mHnHujh,0JU hUhzCJOJQJ^JaJhzCJOJQJ^JaJ1jhz5CJ OJQJU^JaJ mHnHu    1 ? @ A N O Z \ ] ^ l whQ?#hUh CJOJQJ\^JaJ,jhUh CJOJQJU\^JaJh CJOJQJ\^JaJhOLh OJQJ^JhOLh 5OJQJ^JhJ[U5OJQJ^Jjhz0JUh%)hJ[U6OJQJ^JhJ[U6OJQJ^JhJ[UCJOJQJ\^JaJ,jhUhJ[UCJOJQJU\^JaJ2jhUhJ[UCJOJQJU\^JaJl m n p x y ϠϠlϠRϠ2jhUh CJOJQJU\^JaJ2jhhUh CJOJQJU\^JaJ2jhUh CJOJQJU\^JaJ#hUh CJOJQJ\^JaJh CJOJQJ^JaJh CJOJQJ\^JaJ,jhUh CJOJQJU\^JaJ2jxhUh CJOJQJU\^JaJ  g `0  $d%d&d'dNOPQ\$gdU*$d%d&d 'dNOP Q\$gdJ[U,$d%d&d 'dNOP Q\$gdJ[U [$\$gdUm$ [$\$gdU   ϠxgN<2jhz0JU#hhe5CJOJQJ^JaJ1jh95CJOJQJU^JaJmHnHu hhCJOJQJ^JaJh CJOJQJ^JaJ2jhUh CJOJQJU\^JaJ#hUh CJOJQJ\^JaJh CJOJQJ^JaJh CJOJQJ\^JaJ,jhUh CJOJQJU\^JaJ2jXhUh CJOJQJU\^JaJ     # $ & ? 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