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EXCOA-CVT study - CHECKLIST FOR POTENTIAL PARTICIPANTS IN THE STUDY
Thank you for your interest in participating in the EXCOA-CVT study.
In order to become a potential participant in the study we kindly ask you to answer the questions of this form.
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* Required
INVESTIGATOR DETAILS
Investigator NAME
*
Your answer
PROVIDE A PASSWORD FOR YOUR INVESTIGATOR ID PROFILE
*
This password will be used to validate your identification whenever submitting data to the study. In case you forget it, please email us and we will send to the above email a reminder.
Your answer
Investigator EMAIL
*
Your answer
HOSPITAL/MEDICAL CENTER
*
Your answer
COUNTRY
*
Your answer
CITY
Your answer
ADDRESS
Your answer
PHONE
Your answer
FAX
Your answer
WILL YOU/YOUR CENTER BE WILLING TO:
1. COLLECT INCLUSION DATA FROM ALL CEREBRAL VEIN THROMBOSIS (CVT)?
*
YES
NO
2. CONFIRM THE DIAGNOSIS OF CVT BY CT/CTV, MR/MRV OR IA ANGIOGRAPHY?
*
YES
NO
3. COLLECT FOLLOW-UP DATA FROM ALL PATIENTS AT 6, 12 AND 24 MONTHS?
*
YES
NO
REGARDING POST-ACUTE PHASE ANTICOAGULANT TREATMENT
ARE YOU/YOUR CENTER WILLING TO USE THE FOLLOWING ANTICOAGULANT POLICY FOR ALL PATIENTS INCLUDED IN THE EXCOA-CVT STUDY:
*
SHORT-TERM (3-6 months)
LONG-TERM (12 months)
UNCERTAIN AND ACCEPTING TO BE RANDOMIZED
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