SDTM aCRF Annotation Checklist

SDTM aCRF Annotation Checklist

SDTM aCRF Annotation Checklist

By Sarath Annapareddy

Introduction

Creating an SDTM Annotated Case Report Form (aCRF) is a critical step in clinical trial data submission. It ensures that data collected in the CRF maps correctly to SDTM domains, adhering to regulatory and CDISC standards. This checklist serves as a guide to creating a high-quality SDTM aCRF ready for regulatory submission.

1. General Formatting

  • Ensure the aCRF uses the latest SDTM IG version relevant to the study.
  • The document should be clean, legible, and free of overlapping annotations.
  • Page numbers in the aCRF should align with the actual CRF pages.
  • Annotations must be in English, clear, and consistently formatted.
  • Use color coding to differentiate domain mappings, derived variables, and special-purpose annotations.

2. Domain-Level Annotations

  • Annotate each field on the CRF with the corresponding SDTM variable name (e.g., DMAGE, LBTEST).
  • Ensure every field includes an appropriate domain prefix (e.g., DM, AE).
  • Unmapped fields should be labeled with "Not Mapped" or "NM".
  • Ensure proper usage of variable cases (e.g., all uppercase for SDTM variable names).

3. Data Collection Fields

  • Map demographic fields (e.g., SEX, RACE) to the `DM` domain.
  • Adverse event fields (e.g., event name, severity) should map to the `AE` domain.
  • Laboratory test results and units should map to the `LB` domain.
  • Exposure data (e.g., drug start/stop dates) must align with the `EX` domain.
  • Use the `DV` domain for protocol deviations and the `MH` domain for medical history.

4. Special-Purpose Domains

  • SUPPQUAL should be used for non-standard variables.
  • RELREC annotations are required for defining relationships between domains.
  • Free-text comments should map to the `CO` domain.
  • Trial design fields should map to domains like `TA`, `TV`, and `TS`.

5. Derived and Computed Variables

  • Derived variables must be clearly labeled (e.g., "DERIVED" or "CALCULATED").
  • Ensure annotations for variables like BMI reference all contributing fields (e.g., height and weight).
  • Visit variables (e.g., VISITNUM, VISITDY) should align with RFSTDTC.

6. Date and Time Variables

  • All date fields must follow ISO 8601 format (e.g., AESTDTC, EXSTDTC).
  • Derived date variables like VISITDY should be calculated relative to RFSTDTC.

7. Validation and Quality Control

  • Validate the aCRF against the finalized SDTM datasets.
  • Ensure alignment with the Define.xml document.
  • Conduct reviews by the programming and data management teams.
  • Perform a completeness check to ensure no fields are left unannotated.

8. Regulatory Submission Readiness

  • Ensure compliance with the requirements of regulatory authorities (e.g., FDA, PMDA).
  • Submit the aCRF in a searchable, bookmarked PDF format.
  • Verify that all color-coded annotations are visible in grayscale for printed versions.
  • Include a cover page with the study title, protocol number, and version.

Conclusion

A well-annotated SDTM aCRF is crucial for successful regulatory submissions. By following this checklist, you can ensure your aCRF meets compliance requirements and demonstrates traceability between the CRF, datasets, and Define.xml. This meticulous process not only ensures regulatory approval but also enhances the credibility of your clinical trial data.

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