PORTAL Trial

Initial Oxygen for Delivery Room Resuscitation of Preterm

Edit Form

iCAPE - IITM

Scheduled for 9 pm

Screening Form

Eligibility Assessment for Pregnant Women <32 weeks gestation

01-0842

SCREENING ID

ELIGIBLE

ℹ️

Best calculated gestational age: 28 weeks 3 days. Participant is eligible for the study.

Gestation in weeks clearly known? *

Best Estimate GA (Weeks) *

Best Estimate GA (Days)

EDD Date

Method of Assessment *

Site Name *

Site ID

Screening ID *

Mother's First Name *

Mother's Surname

Husband's First Name

Husband's Surname

Maternal UID (CR Number)

Hospital Admission No.

Contact (Maternal)

Contact (Husband)

Major structural anomalies or genetic abnormality

Fetal Hydrops

Decision to forgo resuscitation

Insufficient time for consent/randomization before birth

Intrauterine Fetal Death (IUFD)

Was consent obtained? *

Yes, obtainedNo, refusedNot approached

Relationship to Participant

Consent Taken By

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