Chiari Type I Malformation Radiology Review Form

HEADER:PI NAME[CDASH Std1], Protocol or IRB Number, Protocol Short Title[CDASH Std2]

Subject Initials Subject ID[CDASH Std3]

Electrocardiogram Results

Date:[CDASH Std4] / / Electrocardiogram not performed[CDASH Std5]

Month Day Year

Time:[CDASH Std6] (using 24 hourformat)

(e.g. hh:mm)

Visit Number[CDASH Std7](check one):

Form Number Version Date: 10/20/2016 Page 1 of 1

Visit #

Form Number Version Date: 10/20/2016 Page 1 of 1

HEADER: IRB Number, Title, PI

Position of Subject:[CDASH Std8] Sitting Supine

ECG Measurement/Result[CDASH Std9]

(check one) (check one)

Heart Rate bpm[CDASH Std10] Normal Abnormal Clinically significant?[CDASH Std11] Yes No

PR Interval msec[CDASH Std12]Normal Abnormal Clinically significant?[CDASH Std13] Yes No

QRS Duration msec[CDASH Std14] Normal Abnormal Clinically significant?[CDASH Std15] Yes No

QTc Interval msec[CDASH Std16]Normal Abnormal Clinically significant?[CDASH Std17] Yes No

Cardiac Rhythm: (check one or check all that apply)

Normal Sinus Rhythm / Atrial Flutter / Sinus Tachycardia
Atrial Fibrillation / Type I Second Degree AV Block / SupraVentricular Tachycardia
First–degree AV Block / Type II Second Degree AV Block / Third Degree AV Block
Ventricular Tachycardia / Ventricular Fibrillation / Paced Rhythm
Sinus Bradycardia / Other: (specify) / Other: (specify)

Overall assessment Normal Abnormal Clinically significant?[CDASH Std18] Yes No

ECG done by:

ECG read by:

Comment(s):

Version Date:07/07/2009

[CDASH Std1] Optional
Investigator Identifier (CDASH Domain: Common)
CDASH/SDTM Variable Name: INVID

[CDASH Std2] Highly Recommended
Protocol/Study Identifier (CDASH Domain: Common)
CDASH/SDTM Variable Name: STUDYID

[CDASH Std3] Highly Recommended
Subject Identifier (CDASH Domain: Common)
CDASH/SDTM Variable Name: SUBJID

[CDASH Std4] Recommended/Conditional

Date (CDASH Domain: EG)
CDASH Variable Name: EGDAT
SDTM Variable Name: EGDTC (ISO 8601 format)

[CDASH Std5] Highly Recommended

ECG Not Performed (CDASH Domain: EG)
CDASH Variable Name: EGPERF
SDTM Variable Name: EGSTAT

[CDASH Std6] Recommended/Conditional

Time (CDASH Domain: EG)
CDASH Variable Name: EGTIM
SDTM Variable Name: EGDTC (ISO 8601 format)

[CDASH Std7] Recommended/Conditional

Visit Number (CDASH Domain: EG)
CDASH/SDTM Variable Name: EGTPT

[CDASH Std8] Optional

Position (CDASH Domain: EG)
CDASH/SDTM Variable Name: EGPOS

[CDASH Std9] Highly Recommended

ECG Result (CDASH Domain: EG)
CDASH/SDTM Variable Name: EGORRES

[CDASH Std10] Recommended/Conditional

Units (CDASH Domain: EG)
CDASH/SDTM Variable Name: EGORRESU

[CDASH Std11] Optional