Sub-Domain: Participant Characteristics
CRF: Hospitalization Form
CDE ID | CDE Name | Variable Name | Definition | Short Description | Additional Notes (Question Text) | Permissible Values | Description | Data Type | Disease Specific Instructions | Disease Specific Reference | Population | Classification (e.g., Core) | Version Number | Version Date | CRF Name (CRF Module / Guideline) | Sub Domain Name | Domain Name | Size | Input Restrictions | Min Value | Max Value | Measurement Type | Source | Form Set | Form | Field | Domain | CDASH Variable | CDASH Definition | CDASH Label | Controlled Terminology | Prompt | Essentiality | Question Text | CDASH imp guidance | SDTM IG target | csDSR | PhenX | Data Type | CRF Completion Inst | SDTMIG Target Var | SDTMIG Target Map | Codelist Name | PVs | Pre Pop Value | Query Display | List Style |
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C60138 | Form data correction indicator | FormDataCorrectionInd | Indicator of whether the data collected on the form includes a correction of previously collected data. | Indicator of whether the data collected on the form includes a correction of previously collected data. | Correction | No;Yes | No;Yes | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2021-01-15 14:33:02.0 | Hospitalization Form | Participant Characteristics | General Health History |
Single Pre-Defined Value Selected |
HO | CORRECTED_HOYN |
Any Corrections |
Any Correction |
Were any corrections made? |
N/A | Char | Indicate whether any corrections were made to previously collected data. | (NY) |
Yes; No |
Prompt | Radio | |||||||||||||||||||
C60139 | Hospital admit date | HospitalAdmitDate | Date on which the subject/participant was admitted to a hospital. | Date on which the subject/participant was admitted to a hospital. | Date of Admission (yyyy/mm/dd) | Date or Date & Time | Adult;Pediatric | Supplemental | 1.00 | 2021-01-15 14:35:46.0 | Hospitalization Form | Participant Characteristics | General Health History |
Free-Form Entry |
HO | HOSPITAL_HOSTDAT |
Healthcare Encounter Start Date |
Admission Date |
What was the hospital dmission date? |
HOSTDTC | Char | Record the start date of the healthcare encounter (e.g., date of admission) using this format (DD-MON-YYYY). |
HOSTDTC where HOTERM = HOSPITAL |
Prompt | |||||||||||||||||||||||
C60140 | Hospital admit reason | HospitalAdmitRsn | Reason(s) for which the subject/participant was admitted to the hospital. | Reason(s) for which the subject/participant was admitted to the hospital. | Reason for admission | Acute chest syndrome;Asthma;Congestive heart failure;Infection;Pain;Renal failure;Stroke;Surgery;Other, specify:;Transient red cell aplasia;Transfusion Reaction;Splenic sequestration;Skin ulcers;Priapism;Gall bladder and liver disease;Eye problems;Chelation therapy;Osteomyelitis or osteonecrosis | Acute chest syndrome;Asthma;Congestive heart failure;Infection;Pain;Renal failure;Stroke;Surgery;Other, specify:;Transient red cell aplasia;Transfusion Reaction;Splenic sequestration;Skin ulcers;Priapism;Gall bladder and liver disease;Eye problems;Chelation therapy;Osteomyelitis or osteonecrosis | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2021-01-15 14:39:54.0 | Hospitalization Form | Participant Characteristics | General Health History |
Multiple Pre-Defined Values Selected |
HO | HOSPITAL_HOREAS |
Reason for the Healthcare Encounter |
Reason for the Hospital Admission |
What was the reason for the hosptial admission? |
SUPPHO.QVAL | Char | Provide the reason for the subject's hospital admission. |
SUPPHO.QVAL where SUPPHO.QNAM = "HOREAS" and SUPPHO.QLABEL = "Reason for the Healthcare Encounter" |
Prompt | Radio | ||||||||||||||||||||
C60141 | Hospital admit reason other text | HospitalAdmitRsnOTH | The free-text field related to "Hospital admit reason", specifying other text. | The free-text field related to "Hospital admit reason", specifying other text. | If Other, specify | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2021-01-15 14:54:46.0 | Hospitalization Form | Participant Characteristics | General Health History | 4000 |
Free-Form Entry |
HO | HOSPITAL_HOREASO |
Oth Reason for the Healthcare Encounter |
Specify Other |
If other is selected, specify? |
SUPPHO.QVAL | Char | Provide the reason for the subject's hospital admission. |
SUPPHO.QVAL where SUPPHO.QNAM = "HOREAS" and SUPPHO.QLABEL = "Reason for the Healthcare Encounter" |
Question | ||||||||||||||||||||||
C17409 | Visit date | VisitDate | Date of interview or visit (actually the date when data in the form were captured) | Date of interview or visit | Visit Date (yyyy/mm/dd) | Date or Date & Time | Adult;Pediatric | Supplemental | 3.00 | 2013-06-21 00:00:00.0 | Hospitalization Form | Participant Characteristics | General Health History |
Free-Form Entry |
DeBaun Forms | LB | VISDAT |
Visit Date |
Visit Date |
What [is/was] the date of the visit? |
N/A | Char | Record the [date/start date] of the visit using DD-MON-YYYY format. | Prompt | |||||||||||||||||||||||
C60137 | Event ad hoc identification number text | EventAdHocIDNumTxt | Text field allowing for alphanumeric ad-hoc event identification numbers. | Text field allowing for alphanumeric ad-hoc event identification numbers. | Ad Hoc Event ID | Alphanumeric | Adult;Pediatric | Supplemental | 1.00 | 2021-01-15 14:28:33.0 | Hospitalization Form | Participant Characteristics | General Health History | 50 |
Free-Form Entry |
HO | HOSPID |
HO Sponsor-Defined Identifier |
Event ID |
What was the event ID? |
HOSPID | Char | If collected on the CRF, sponsor may insert instructions to ensure each record has a unique identifier. | Prompt |