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Case Report Forms

Case Report Forms

Protocol _ June 28

Research Coordinator

Therapist

1 - Screening

(ICU Admission)

Form 1 Screening

1 - Screening

(ICU Admission)

N/A

2 - Consent

(ICU Admission)

Form 3 Baseline

2 - Consent

(ICU Admission)

N/A

3 - Randomization

(Randomized / Study Entry ≤4 d MV)

Form 2 Randomization

4 - Daily ICU Responsibilites

(30 min cycling + Routine PT OR Routine PT)

Form 4 Daily Data

Form 4A Daily Data While on Ward

5 - ICU Awakening

(Awake)

Test #1

Form 8 ICU Awakening IPAT

6 - ICU Discharge

(ICU Discharge)

Test #2

Form 10 ICU Discharge Ax - Research Coordinator Assessment

7 - Pre-Hospital Discharge

(3 d Post-ICU Discharge)

N/A

8 - Hospital Discharge, Death or Withdrawal

(Hospital Discharge)

Test #4

Form 12 Hospital Discharge Ax

Form 14 Final Status and Outcomes Ax

9 - 90 Days After Treatment

(90 Day After Enrollment)

Test #5

3 - Randomization

(Randomized / Study Entry ≤4 d MV)

N/A

4 - Daily ICU Responsibilites

(30 min cycling + Routine PT OR Routine PT)

Routine PT and Cycling Therapy Forms

Routine PT Only Therapy Forms

5 - ICU Awakening

(Awake)

Test #1

Form 7 ICU Awakening Ax: Strength and Function

6 - ICU Discharge

(ICU Discharge)

Test #2

Form 9 ICU Discharge Ax - Strength and Function

7 - Pre-Hospital Discharge

(3 d Post-ICU Discharge)

Test #3

Form 9A 3 Days Post ICU Discharge Ax - Blinded

Form 13 PT Post - ICU Discharge - Ward PT

8 - Hospital Discharge, Death or Withdrawal

(Hospital Discharge)

Test #4

Form 11 Hospital Discharge Ax - Blinded - Strength and Function

9 - 90 Days After Treatment

(90 Day After Enrollment)

N/A