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Case report form sample

Case report form sample 2026

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The document is a case report form for the California Emerging Infections Program's Human Papillomavirus Vaccine Impact Monitoring Project (HPV-IMPACT). It aims to collect patient information regarding cervical pre-cancers under public health surveillance, ensuring confidentiality of the data. The form includes sections for patient and provider information, cervical pathology, race and insurance details, HPV vaccine history, Pap and HPV testing history, and underlying illnesses.

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Click ‘Get Form’ to open the case report form sample in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, last four digits of their SSN, address, medical record number, date of birth, age, and contact details for both the patient and provider.
Next, complete the 'Provider Information' section with the provider's name and practice details.
In the 'Cervical Pathology' section, input the specimen collection date and pathology lab information.
Proceed to 'Patient Race & Insurance Information'. Check all applicable boxes for race and ethnicity, and provide insurance details as required.
For 'HPV Vaccine History', indicate if vaccination status is documented. If yes, provide details about each dose administered including dates and type of vaccine.
Finally, fill out the 'Pap and HPV Testing History' section with relevant test results before the specified date. Include any underlying illnesses if applicable.

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What are the different types of case report forms?

Types of CRF in Clinical Research Paper-Based CRF. Historically, clinical trials relied on physical documents for data entry. Electronic Case Report Form (eCRF) With technological advancements, most trials have transitioned to electronic case report form design.

What is included in the case report?

The information included in a case report can vary depending on the nature of the case, but generally, it includes the following: Time: The time when the incident occurred or when it was reported. Witness: Details of any individuals who witnessed the incident. Location: The place where the incident occurred.

How should a case report be formatted?

Case reports generally take the format of: Background. Case presentation. Observations and investigation. Diagnosis. Treatment. Outcome. Discussion.

Who makes the case report form?

The sponsor is responsible for designing a CRF that accurately represents the protocol of the clinical trial, as well as managing its production, monitoring the data collection and auditing the content of the filled-in CRFs.

What is the structure of a case report?

Case reports should encompass the following five sections: an abstract, an introduction with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, and a brief summary of the case and a conclusion.

How to create a case report form?

Important part of the CRF is an informative header and footer, which can be customized. [7] In general, the header includes protocol ID, site code, subject ID, and patient initials. Whereas, the footer includes investigators signature, date of signature, version number, and page number.

How do you write a case report step by step?

Case reports may contain a demographic profile of the patient that usually describes an unusual or novel occurrence. Step 1: Identify the Category of Your Case Report. Step 2: Select an Appropriate Journal. Step 3: Structure Your Case Report According to the Journal Format. Step 4: Start Writing.

Case report form sample 2026

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