ICH E6(R3) 1.11
A printed, optical, or electronic document designed to record all protocol-required information on each trial subject.
The case report form represents the primary tool for capturing clinical trial data in a structured, standardized format that facilitates analysis and regulatory review. Each CRF is specifically designed to collect the information required by the protocol, translating the study's scientific objectives into concrete data collection instruments. Whether in paper format or, increasingly common today, as electronic case report forms, these documents must enable accurate, complete, and legible recording of all protocol-specified data in a manner that supports verification against source documents.
Electronic case report forms have become the predominant format in modern clinical trials, offering significant advantages in data quality, efficiency, and auditability. eCRF systems typically incorporate programmed edit checks that prompt users when entered data falls outside expected ranges, when logical inconsistencies exist between data points, or when required fields are incomplete. These real-time validation checks reduce transcription errors and missing data, significantly improving data quality compared to paper-based collection. Electronic systems also maintain comprehensive audit trails that document every data entry, modification, and the identity of the individual making each change, supporting data integrity requirements.
The design of case report forms requires careful attention to ensure that data collection aligns precisely with source documents and protocol requirements. Forms must be intuitive for site personnel to complete accurately, must capture data at the appropriate level of granularity for planned analyses, and must facilitate the data cleaning and analysis processes that occur after collection. The design should minimize unnecessary complexity while ensuring all required data elements are captured. Sponsors typically develop detailed CRF completion guidelines that provide specific instructions for every field, promoting consistent data entry across all participating sites and reducing query rates during data cleaning.
Whether paper or electronic, case report forms must meet regulatory requirements for clinical trial records. Data must be attributable to the person who entered it, entries must be legible and understandable, records must be contemporaneous with the events they document, data must represent original recordings or certified copies, and entries must be accurate. For electronic systems, additional requirements include system validation, user access controls, electronic signature capabilities, and secure data storage with appropriate backup procedures.
Data entry
"Following each study visit, the clinical research coordinator transcribed the participant's vital signs, laboratory results, and assessment responses from the source documents into the electronic case report form, resolving any edit checks triggered by the system."
Query resolution
"The data manager issued a query through the eCRF system when the entered blood pressure value appeared implausible, requesting that the site verify the measurement against the original source document and correct the entry if necessary."
CRF design
"The CRF development team designed forms that mirrored the structure of source documents at most sites, reducing transcription complexity and improving data entry accuracy."
Documents that individually and collectively permit evaluation of the conduct of a study and the quality of the data produced.
A compilation of the clinical and nonclinical data on the investigational product that are relevant to the study of the product in human subjects.
A document that describes the objectives, design, methodology, statistical considerations, and organization of a clinical trial.
A written description of a change or formal clarification to a protocol that must be approved by the sponsor, IRB/IEC, and regulatory authorities before implementation.
Original documents, data, and records from which a subject's clinical trial data are obtained, including hospital records, clinical and office charts, laboratory notes, memoranda, pharmacy records, and patient diaries.
ICH E6(R3) 1.11
A printed, optical, or electronic document designed to record all protocol-required information on each trial subject.
The case report form represents the primary tool for capturing clinical trial data in a structured, standardized format that facilitates analysis and regulatory review. Each CRF is specifically designed to collect the information required by the protocol, translating the study's scientific objectives into concrete data collection instruments. Whether in paper format or, increasingly common today, as electronic case report forms, these documents must enable accurate, complete, and legible recording of all protocol-specified data in a manner that supports verification against source documents.
Electronic case report forms have become the predominant format in modern clinical trials, offering significant advantages in data quality, efficiency, and auditability. eCRF systems typically incorporate programmed edit checks that prompt users when entered data falls outside expected ranges, when logical inconsistencies exist between data points, or when required fields are incomplete. These real-time validation checks reduce transcription errors and missing data, significantly improving data quality compared to paper-based collection. Electronic systems also maintain comprehensive audit trails that document every data entry, modification, and the identity of the individual making each change, supporting data integrity requirements.
The design of case report forms requires careful attention to ensure that data collection aligns precisely with source documents and protocol requirements. Forms must be intuitive for site personnel to complete accurately, must capture data at the appropriate level of granularity for planned analyses, and must facilitate the data cleaning and analysis processes that occur after collection. The design should minimize unnecessary complexity while ensuring all required data elements are captured. Sponsors typically develop detailed CRF completion guidelines that provide specific instructions for every field, promoting consistent data entry across all participating sites and reducing query rates during data cleaning.
Whether paper or electronic, case report forms must meet regulatory requirements for clinical trial records. Data must be attributable to the person who entered it, entries must be legible and understandable, records must be contemporaneous with the events they document, data must represent original recordings or certified copies, and entries must be accurate. For electronic systems, additional requirements include system validation, user access controls, electronic signature capabilities, and secure data storage with appropriate backup procedures.
Data entry
"Following each study visit, the clinical research coordinator transcribed the participant's vital signs, laboratory results, and assessment responses from the source documents into the electronic case report form, resolving any edit checks triggered by the system."
Query resolution
"The data manager issued a query through the eCRF system when the entered blood pressure value appeared implausible, requesting that the site verify the measurement against the original source document and correct the entry if necessary."
CRF design
"The CRF development team designed forms that mirrored the structure of source documents at most sites, reducing transcription complexity and improving data entry accuracy."
Documents that individually and collectively permit evaluation of the conduct of a study and the quality of the data produced.
A compilation of the clinical and nonclinical data on the investigational product that are relevant to the study of the product in human subjects.
A document that describes the objectives, design, methodology, statistical considerations, and organization of a clinical trial.
A written description of a change or formal clarification to a protocol that must be approved by the sponsor, IRB/IEC, and regulatory authorities before implementation.
Original documents, data, and records from which a subject's clinical trial data are obtained, including hospital records, clinical and office charts, laboratory notes, memoranda, pharmacy records, and patient diaries.