|
|
<script>
|
|
|
$(function() {
|
|
|
$( "#txt_dateDeath" ).datepicker({
|
|
|
showWeek: true,
|
|
|
dateFormat: 'dd/M/yy',
|
|
|
firstDay: 1
|
|
|
});
|
|
|
});
|
|
|
</script>
|
|
|
<div class="header_frm_page">
|
|
|
<label class="title1">Study Termination</label>
|
|
|
</div>
|
|
|
<br/><br/>
|
|
|
<label>Termination/Study Completion Date: </label><input type="text" name="txt_date" /><br/><br/>
|
|
|
<label>Did the subject complete the study?</label>
|
|
|
<input type="radio" name="rbn_opt"/>Yes <input type="radio" name="rbn_opt"/>No*<br/>
|
|
|
<small>*If No, indicate reason for early termination early</small><br/><br/>
|
|
|
<label>Primary reason for early termination (Select only one). Comment required below.</label><br/>
|
|
|
<div id="content_cols">
|
|
|
<div id="col_left" style="float: left; border: 0px solid #1cc">
|
|
|
<input type="radio" name="chkReasons"/>Adverse Event<br/>
|
|
|
<input type="radio" name="chkReasons"/>Death<br/>
|
|
|
<input type="radio" name="chkReasons"/>Protocol Violation<br/>
|
|
|
<input type="radio" name="chkReasons"/>Noncompliance<br/>
|
|
|
<input type="radio" name="chkReasons"/>Lost to follow-up<br/>
|
|
|
<input type="radio" name="chkReasons"/>Voluntary withdrawal<br/>
|
|
|
<input type="radio" name="chkReasons"/>Other<br/>
|
|
|
</div>
|
|
|
<div id="col_right" style="float: left; padding-top: 20px; padding-left: 30px; border: 0px solid #ccc">
|
|
|
<label>Date of death: </label>
|
|
|
<input type="text" name="txt_dateDeath" id="txt_dateDeath" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='DD/MMM/YYYY';" value="DD/MMM/YYYY" />
|
|
|
</div>
|
|
|
<div style="clear: both; overflow: hidden"></div>
|
|
|
</div>
|
|
|
<br/>
|
|
|
<label>Comments required for early termination:</label><br/>
|
|
|
<textarea name="txa_comment" cols="50" rows="5"></textarea>
|
|
|
<p>I have reviewed all the information contained in the case report form and<br/> acknowledge that it is accurate and complete</p>
|
|
|
<br/><br/><br/><br/>
|
|
|
<table class="tbl_general">
|
|
|
<tbody>
|
|
|
<tr>
|
|
|
<td>
|
|
|
<input type="text" name="txt" value="" style="border-bottom: 1px solid #333; border-left: 0; border-right: 0; border-top: 0; width: 400px" />
|
|
|
</td>
|
|
|
<td>
|
|
|
<input type="text" name="txt" value="" style="border-bottom: 1px solid #333; border-left: 0; border-right: 0; border-top: 0; width: 200px" />
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align: center"><label>Investigators Signature</label></td>
|
|
|
<td style="text-align: center"><label>Date</label></td>
|
|
|
</tr>
|
|
|
</tbody>
|
|
|
</table>
|
