Investigator statement: I have reviewed the data recorded in this CRF and confirm that the data are accurate and complete Investigator name Investigator signature Date CRF confirmed Time CRF confirmed |__|__|-|__|__|__|-|__|__|__|__| |__|__|:|__|__| 1 DEMOGRAPHICS DM What is the subject’s date of |__|__|-|__|__|__|-|__|__|__|__| BRTHDAT BRTHDTC OR, if BRTHDAT unknown, years months |__|__| |__|__| AGEU AGEU what is the subject’s age? AGE AGE What is the sex of the If other, Male Female Other subject? specify SEX SEXOTH What is the race of the Black White Coloured Indian Asian Other subject? CRACE RACE If other, specify RACEOTH PREGNANCY STATUS RP If yes, date of last menstrual period |__|__|__|__| Is the subject pregnant? Yes No UNK NA (LMP) RPTEST= Last RPORRES where RPTEST=Last Menstrual RPTEST=Pregnant During the Study Menstrual Period Start Date Period Start Date RPTESTCD=PREGST RPTESTCD=LMPSTDTC RPORRES where RPTEST = Pregnant During the Study If pregnant, estimate |__|__| Weeks gestational age RPORRES RPTEST=Estimated Gestational RPORRESU where RPTEST=Estimated Gestational Age RPTEST=Estimated Gestational Age Age RPTESTCD=EGESTAGE If other, specify Gestational age determined by RPMETHOTH Fundal ht LMP Ultrasound Other RPMETHOD where RPTESTCD=EGESTAGE
Investigator statement: I have reviewed the data recorded in this CRF and confirm that the data are accurate and complete Investigator name Investigator signature Date CRF confirmed Time CRF confirmed |__|__|-|__|__|__|-|__|__|__|__| |__|__|:|__|__| 1 DEMOGRAPHICS DM What is the subject’s date of BRTHDAT BRTHDTC |__|__|-|__|__|__|-|__|__|__|__| OR, if BRTHDAT unknown, what is the subject’s age? |__|__| years AGEU AGE |__|__| months AGEU AGE What is the sex of the subject? SEX Male Female Other If other, specify SEXOTH What is the race of the subject? CRACE RACE Black White Coloured Indian Asian Other If other, specify RACEOTH PREGNANCY STATUS RP Is the subject pregnant? RPTEST=Pregnant During the Study RPTESTCD=PREGST Yes No UNK NA If yes, date of last menstrual period (LMP) RPTEST= Last Menstrual Period Start Date RPTESTCD=LMPSTDTC RPORRES where RPTEST=Last Menstrual Period Start Date RPORRES where RPTEST = Pregnant During the Study If pregnant, estimate gestational age RPTEST=Estimated Gestational Age RPTESTCD=EGESTAGE |__|__| RPORRES RPTEST=Estimated Gestational Age Weeks RPORRESU where RPTEST=Estimated Gestational Age Gestational age determined by RPMETHOD where RPTESTCD=EGESTAGE Fundal ht LMP Ultrasound Other If other, specify RPMETHOTH |__|__|__|__|