Below is a collection of Case Report Forms (CRFs) from a harmonized cohort study of acutely ill hospitalized children who are followed for six months following discharge in Africa and Asia to better understand risk factors and mechanisms for both acute and post-discharge mortality. Click on each button to access the relevant CRFs.
Choose a site / project above to view resources.
Site / Project
BANFORA
CHAIN Daily Record 1.61CHAIN Daily Record 1.61 4th October 2018CHAIN Day 180 Follow-up v1.63 20th August 17CHAIN Day 180 young infants Follow-up v2.0CHAIN Day 45 Follow-up v1.63 20th August 17CHAIN Day 45 young infants Follow-up v2.0CHAIN Day 90 Follow-up v1.63 20th August 17CHAIN Day 90 young infants Follow-up v2.0CHAIN DISCHARGE CRF V1.62 BanforaCHAIN Discharge Young Infants CRF V2.0CHAIN Enrollment-CRF v1.63 BanforaCHAIN Household Survey CRF v1.63 BanforaCHAIN Inpatient Verbal Autopsy CRF v1.60 BanforaCHAIN Outpatient Verbal Autopsy CRF v1.59 BanforaCHAIN RE- DISCHARGE CRF V1.59 BanforaCHAIN READMISSION CRF V1.62 BanforaCHAIN unscheduled visit V1.60 6th March 2017Confirmatory HIV test CRF v1.59 BanforaConfirmatory HIV test CRF v1.60Download all Main Banfora CHAIN CRFSDownload all Young Infant Banfora CRFsKiswahili PHQ 9 BanforaPHQ - Questions plus extra 10th question Banfora
Site / Project
BLANTYRE
CHAIN community enrollment CRF v1.62 blantyreCHAIN Daily Record 1.61 blantyreCHAIN Day 180 Follow-up v1.63 blantyreCHAIN Day 45 Follow-up v1.63 blantyreCHAIN Day 90 Follow-up v1.63 blantyreCHAIN DISCHARGE CRF V1.62 blantyreCHAIN Enrollment-CRF v1.64 blantyreCHAIN Household Survey CRF v1.63 malawiCHAIN Inpatient Verbal Autopsy CRF v1.60 blantyre(1)CHAIN Outpatient Verbal Autopsy CRF v1.59 blantyreCHAIN RE- DISCHARGE CRF V1.59 blantyreCHAIN READMISSION CRF V1.62 blantyreCHAIN Referral CRF V1.60 2nd March 2017 blantyreCHAIN STUDY CONCLUSION v1.63 10JAN2018CHAIN unscheduled visit V1.60 6th March 2017 blantyreConfirmatory HIV test CRF v1.60 blantyreDaily clinical signs monitoring V2 FMDownload all Blantyre CRFs as a ZIP (Main CRFs)Download all CRFs as a ZIP (MITS CRFs)Download all CRFs as a ZIP (Nutrition CRFs)IC Hospital Stay & Followups CRF version 1.02Infant TBW Sample Sheet version 1.02ITS in CHAIN CRF 8 GI Histopathology H&E Results CRF V.2 FINAL 2018 12 13Maternal TBW Sample Sheet version 1.02MITS in CHAIN CRF 1 Consent CRF V.4 FINAL 2019 05 15MITS in CHAIN CRF 2 GI Sampling CRF V.2 FINAL 2018 11 21 - SAMPLEMITS in CHAIN CRF 3 Core Sampling CRF V.3 FINAL 2019 05 01MITS in CHAIN CRF 4 Initial Transporting Processing and Storing of Samples CRF V.3 FINAL 2019 05 01MITS in CHAIN CRF 5 CLO Test SOP CRF V.2 FINAL 2019 05 01MITS in CHAIN CRF 6 Histopathology Processing and Embedding CRF V.2 FINAL 2018 12 13MITS in CHAIN CRF 7 Core Histopathology H&E Results CRF V.2 FINAL 2019 05 01MITS in CHAIN CRF 9 Histopathology Giemsa Gastric Biopsy Results CRF V.1 FINAL 2018 08 20MITS in CHAIN Eligibility Screening Form non CHAIN patients V.1 FINAL 2019 05 29MITS in CHAIN Rumour Surveillance Form SOP CRF V.1 FINAL 2018 08 01PHQ - Questions plus extra 10th question BlantyreRepeated WFR Day 14 version 1.01 BlantyreRepeated WFR Day 45 version 1.01 BlantyreRUTF intake Form version 1.01Saliva Sample Sheet-DOD version 1.01 BlantyreWFR- 3days post dis-version 1.01
Site / Project
BLANTYRE PB SAM TRIAL
Site / Project
Data Collection Tools
Additional data for younger infantsCommunity EnrolmentDaily RecordDay 180 Follow-upDay 45 Follow-upDay 90 Follow-upDischargeHIV confirmatory testHousehold surveyInpatient verbal autopsyOutpatient verbal autopsyPHQ9 plus 10th extra questionRadiology testReadmissionReferralStudy conclusionUnscheduled visitYounger infants enrolment
Site / Project
DHAKA
24 hour Urine Specimen Collection FormCHAIN Daily Record 1.61 dhakaCHAIN Day 180 Follow-up v1.63 dhakaCHAIN Day 45 Follow-up v1.63 dhakaCHAIN Day 90 Follow-up v1.63 dhakaCHAIN DISCHARGE CRF V1.62 dhakaCHAIN Enrollment-CRF infants under 2m v2.2CHAIN Enrollment-CRF v1.63 dhakaCHAIN Heamatology and Biochemistry Request Form v1.62CHAIN Household Survey CRF v1.63 dhakaCHAIN Inpatient Verbal Autopsy CRF v1.60 dhakaCHAIN Outpatient Verbal Autopsy CRF v1.59 dhakaCHAIN Radiology results V1.59 CRF dhakaCHAIN READMISSION CRF V1.62 dhakaDaily clinical signs monitoringDownload all main Dhaka CHAIN CRFsDownload all Nutrition CRFsDownload all Young Infants Dhaka CRFsFresh Bulk Stool Specimen Collection FormInfant TBW Sample Sheet version 1.02Kiswahili PHQ 9 DhakaMaternal TBW Sample SheetPHQ - Questions plus extra 10th question DhakaRepeated WFR Day 14 version 1.01 DhakaSaliva Sample Sheet-DOD version 1.01 DhakaWFR- 3days post dis-version 1.01
Site / Project
FLACSAM TRIAL
File note templateFLACSAM Confirmatory HIV test v1.0FLACSAM Daily Record v1.3FLACSAM DAY 14 v1.2FLACSAM DAY 45 v1.2FLACSAM DAY 90 v1.2FLACSAM DISCHARGE v1.3FLACSAM Inpatient Verbal Autopsy 1.0FLACSAM Microbiology Results 1.0FLACSAM NON trial Enrolment v1.4FLACSAM Outpatient Verbal Autopsy v1.0FLACSAM READMISSION v1.1FLACSAM SAE v1.1FLACSAM Study Conclusion v1.2FLACSAM TOXICITY v1.0FLACSAM Trial Enrolment v1.6Protocol violation_deviation SSPScreening SSP
Site / Project
KAMPALA
CHAIN Daily Record 1.61 kampalaCHAIN Day 180 Immunology Follow-up v2.0 kampalaCHAIN Day 45 Immunology Follow-up v2.0 kampalaCHAIN Day 90 Immunology Follow-up v2.0CHAIN DISCHARGE CRF V1.62 KampalaCHAIN Enrollment-CRF v1.63 KampalaCHAIN Household Survey CRF v1.63 KampalaCHAIN Immunology discharge CRF v2.0 kampalaCHAIN Immunology Outpatient SAM day 90 kampalaCHAIN IMMUNOLOGY READMISSION CRF V2.0 April 19 kampalaCHAIN Inpatient Verbal Autopsy CRF v1.60 KampalaCHAIN Outpatient Verbal Autopsy CRF v1.59CHAIN RE- DISCHARGE CRF V1.59 KampalaCHAIN RE- DISCHARGE CRF V1.59 KampalaCHAIN READMISSION CRF V1.62 KampalaCHAIN study conclusion v2.0 kampalaConfirmatory HIV test CRF v1.59 KampalaDownload all CRFs here (Immunology)Download all CRFs here (Main CRFs)Download all CRFs here (Young Infants)
Site / Project
KAMPALA PB SAM TRIAL
Site / Project
KARACHI
CHAIN BMC CRF CommunityParticipant v2.62CHAIN BMC Young infants discharge CRF v2.1 karachiCHAIN Daily Record 1.61 4th October 2018- KarachiCHAIN Daily Record 1.61 karachiCHAIN Day 180 BMCFollow-up v2.0 karachiCHAIN Day 45 BMC infants Follow-up v2.0 karachiCHAIN Day 45 Follow-up v1.63 20th August 17- KarachiCHAIN Day 90 BMCFollow-up v2.0 karachiCHAIN DISCHARGE CRF V1.62 KarachiCHAIN Enrollment-CRF infants under 2m v2.2 karachiCHAIN Enrollment-CRF v1.63 KarachiCHAIN Household Survey CRF v1.63 KarachiCHAIN Inpatient Verbal Autopsy CRF v1.60 KarachiCHAIN Outpatient Verbal Autopsy CRF v1.59 KarachiCHAIN RE- DISCHARGE CRF V1.59 KarachiCHAIN READMISSION CRF V1.62 KarachiCHAIN study conclusion v2.0 BMC karachiCHAIN unscheduled visit V1.60 6th March 2017 KarachiConfirmatory HIV test CRF v1.59 KarachiConfirmatory HIV test CRF v1.60 karachiDownload all BMC CRFsDownload all Main Karachi CRFsKiswahili PHQ 9 KarachiPHQ - Questions plus extra 10th question Karachi
Site / Project
KILIFI
CHAIN community enrollment CRF v1.61_mbagathi.pdfCHAIN Daily Record 1.60_6th Feb 2017_mbagathi.pdfCHAIN Daily Record 1.61_kilifi.pdfCHAIN Day 180 Follow-up v1.62_mbagathi.pdfCHAIN Day 180 Immunology Follow-up v2.0_Kilifi.pdfCHAIN Day 45 Follow-up v1.62_mbagathi.pdfCHAIN Day 45 Immunology Follow-up v2.0_kilifi.pdfCHAIN Day 45 young infants Follow-up v2.0.pdfCHAIN Day 90 Follow-up v1.62_mbagathi.pdfCHAIN Day 90 Immunology Follow-up v2.0.pdfCHAIN Day 90 young infants Follow-up v2.0.pdfCHAIN DISCHARGE CRF V1.61_mbagathi.pdfCHAIN Discharge Young Infants CRF V2.0.pdfCHAIN Enrollment-CRF_ infants under 2m v2.2.pdfCHAIN Enrollment-CRF_ v1.64_mbagathi.pdfCHAIN HOUSEHOLD ASSESSMENT v1.61_mbagathi.pdfCHAIN Immunology discharge CRF v2.0_kilifi.pdfCHAIN Immunology Outpatient SAM day 90_KILIFI.pdfCHAIN IMMUNOLOGY READMISSION CRF V2.0 April 19_KILIFI.pdfCHAIN Radiology results V1.59 CRF_mbagathi.pdfCHAIN READMISSION CRF V1.61_mbagathi.pdfCHAIN Referral CRF V1.59_mbagathi.pdfCHAIN study conclusion v1.61_mbagathi.pdfCHAIN study conclusion v2.0 _kilifi.pdfCHAIN study conclusion v2.0 young infants.pdfCHAIN unscheduled visit V1.59_mbagathi.pdfCHAIN_Household_Survey_CRF v1.60 23rd feb 2017_mbagathi.pdfCHAIN_Inpatient Verbal Autopsy CRF v1.59_mbagathi.pdfCHAIN_Outpatient Verbal Autopsy CRF v1.59_mbagathi.pdfConfirmatory HIV test CRF v1.59_mbagathi.pdfConfirmatory HIV test CRF v1.60.pdfDownload Immunology CRFsDownload Main Kilifi CRFsDownload Young Infants CRFsKiswahili PHQ 9.pdfPHQ questions plus extra 10th question Kilifi
Site / Project
KILIFI PB SAM TRIAL
List of CRFs PB-SAM KilifiPB SAM Site Weekly Screening Chart KilifiPB_SAM_Screening_Form_V1.3PB-SAM Conclusion v1.1 KilifiPB-SAM D60 Follow-up v1.1 KilifiPB-SAM Daily Admission CRF v1.1PB-SAM Daily Record v1.3PB-SAM Enrollment-CRF v1.5PB-SAM Note to File v1.0 KilifiPB-SAM Protocol Deviation_Violation CRF v1.0 KilifiPB-SAM TOXICITY-CRF v1.0
Site / Project
Lab PB SAM TRIAL
Site / Project
Matlab
CHAIN community enrollment CRF v1.63CHAIN DISCHARGE CRF V1.62 MatlabCHAIN Enrollment-CRF 2nd July 2018 v1.64CHAIN Household Survey CRF v1.63 MatlabCHAIN Inpatient Verbal Autopsy CRF v1.59 matlabCHAIN Outpatient Verbal Autopsy CRF v1.59 MatlabCHAIN RE- DISCHARGE CRF V1.59 MatlabCHAIN READMISSION CRF V1.62 MatlabCHAIN unscheduled visit V1.60 6th March 2017 MatlabConfirmatory HIV test CRF v1.59 MatlabDownload all CRFs
Site / Project
MBAGATHI PB SAM TRIAL
Site / Project
MIGORI
CHAIN BMC CRF HospitalParticipant v2.62CHAIN community enrollment CRF v1.61 migoriCHAIN Daily Record 1.61 MIGORICHAIN Daily Record 1.61 migoriCHAIN Day 180 BMCFollow-up v2.0 migoriCHAIN Day 180 Follow-up v1.61 migoriCHAIN Day 180 young infants Follow-up v2.0 MIGORICHAIN Day 45 BMC infants Follow-up v2.0 migoriCHAIN Day 45 Follow-up v1.62 migoriCHAIN Day 45 young infants Follow-up v2.0 MIGORICHAIN Day 90 BMCFollow-up v2.0 migoriCHAIN Day 90 Follow-up v1.61 migoriCHAIN Day 90 young infants Follow-up v2.0 MIGORICHAIN DISCHARGE CRF V1.61 migoriCHAIN Discharge Young Infants CRF V2.0 MIGORICHAIN Enrollment-CRF infants under 2m v2.2 MIGORICHAIN Enrollment-CRF infants under 2m v2.2 migoriCHAIN Enrollment-CRF v1.64 migoriCHAIN HOUSEHOLD ASSESSMENT v1.61 migoriCHAIN Household Survey CRF v1.60 23rd feb 2017 migoriCHAIN Inpatient Verbal Autopsy CRF v1.59 migoriCHAIN Radiology results V1.59 CRF 08Jan2017 migoriCHAIN RE- DISCHARGE CRF V1.59 migoriCHAIN READMISSION CRF V1.60 16th Feb 2017 migoriCHAIN Referral CRF V1.59 migoriCHAIN study conclusion v1.62 migoriCHAIN study conclusion v2.0 BMC migoriCHAIN study conclusion v2.0 young infants MIGORICHAIN unscheduled visit V1.59 migoriConfirmatory HIV test CRF v1.59 migoriConfirmatory HIV test CRF v1.60 MIGORIConfirmatory HIV test CRF v1.60 migoriDown load all CRFs as a ZIP fileDownload all CRFsDownload all Migori CRFs as a ZIP fileKiswahili PHQ 9 MigoriPHQ - Questions plus extra 10th question MigoriPHQ - Questions plus extra 10th question Migori
Site / Project
MIGORI PB SAM TRIAL
Site / Project
NAIROBI
1a CHAIN Enrollment-CRF infants under 2m v2.2 MBAGATHa1b CHAIN Community Enrollment-CRF infants bmc MBAGATHI(1)2.CHAIN Daily Record 1.61 mbagathi3.CHAIN BMC Young infants discharge CRF v2.1 mbagathi4.CHAIN Day 45 BMC infants Follow-up v2.0 Mbagathi5.CHAIN Day 90 BMCFollow-up v2.0 mbagathi6.CHAIN Day 180 BMCFollow-up v2.0 mbagathi7.CHAIN study conclusion v2.0 BMC mbagathi(1)CHAIN community enrollment CRF v1.61 mbagathiCHAIN Daily Record 1.60 6th Feb 2017 mbagathiCHAIN Day 180 Follow-up v1.62 mbagathiCHAIN Day 45 Follow-up v1.62 mbagathiCHAIN Day 90 Follow-up v1.62 mbagathiCHAIN DISCHARGE CRF V1.61 mbagathiCHAIN Enrollment-CRF v1.64 mbagathiCHAIN HOUSEHOLD ASSESSMENT v1.61 mbagathiCHAIN Household Survey CRF v1.60 23rd feb 2017 mbagathiCHAIN Inpatient Verbal Autopsy CRF v1.59 mbagathiCHAIN Outpatient Verbal Autopsy CRF v1.59 mbagathiCHAIN Radiology results V1.59 CRF mbagathiCHAIN READMISSION CRF V1.61 mbagathiCHAIN Referral CRF V1.59 mbagathiCHAIN study conclusion v1.61 mbagathiCHAIN unscheduled visit V1.59 mbagathiConfirmatory HIV test CRF v1.59 mbagathiConfirmatory HIV test CRF v1.59 migoriConfirmatory HIV test CRF v1.60 mbagathiDownload all as a ZIP fileDownload all BMC CRFsKiswahili PHQ 9 NairobiPHQ - Questions plus extra 10th question Nairobi