National Archive of Computerized Data on Aging

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Name
Label/Question

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Subject ID

Subject ID: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Report date

Report Date:

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Event

Acute Baseline Alert/Adverse Event (Mark all that apply)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Event, specify

If Acute Baseline Alert/Adverse Event: CG Severe medical problem, Specify: ____________________

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Date event month

Date of Acute Baseline Alert/Adverse Event: Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Date event day

Date of Acute Baseline Alert/Adverse Event: Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Date event year

Date of Acute Baseline Alert/Adverse Event: Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Treatment related

Acute Baseline Alert/Adverse Event: Treatment Related?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Status of event

Acute Baseline Alert/Adverse Event: Event status resolved/controlled?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Resolution date month

Date of Resolution - Acute Baseline Alert/Adverse Event (if applicable): Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Resolution date day

Date of Resolution - Acute Baseline Alert/Adverse Event (if applicable): Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Resolution date year

Date of Resolution - Acute Baseline Alert/Adverse Event (if applicable): Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

REACH certification number

2. REACH II Certification Number: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Report date

Report Date:

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Subject ID

Subject ID: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Date event month

Date of Acute Baseline Alerts/Adverse Events: Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Date event day

Date of Acute Baseline Alerts/Adverse Events: Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Date event year

Date of Acute Baseline Alerts/Adverse Events: Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Event

Event Code

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Resolution date month

Date of Resolution - Acute Baseline Alert/Adverse Event: Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Resolution date day

Date of Resolution - Acute Baseline Alert/Adverse Event: Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

Resolution date year

Date of Resolution - Acute Baseline Alert/Adverse Event: Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

REACH certification number

1.1. Reach II Certification Number: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

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