ID

10343

Description

DTH Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF1A2AFC-A449-1B00-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF1A2AFC-A449-1B00-E034-0003BA3F9857

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
Uploaded on

May 28, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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DTH

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1 forms  
Patient death
Description

Patient death

Record date of death
Description

DeathDocumentedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
Was an autopsy performed
Description

AutopsyPerformedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25153
UMLS 2011AA ObjectClass
C0004398
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
Enter Appropriate Cause Of Death Code Below. List In Order Of Decreasing Severity
Description

Enter Appropriate Cause Of Death Code Below. List In Order Of Decreasing Severity

Primary cause of death
Description

PatientDeathPatientDeathPrimaryReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus ValueDomain
C25251
UMLS 2011AA ValueDomain
C0205225
Other, specify below
Description

DeathContributingSymptomSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Metathesaurus Property
CL317017
Other, specify below
Description

DeathContributingSymptomSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Metathesaurus Property
CL317017
Other, specify below
Description

DeathContributingSymptomSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Metathesaurus Property
CL317017
Other, specify below
Description

DeathContributingSymptomSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Metathesaurus Property
CL317017
Other, specify below
Description

DeathContributingSymptomSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Metathesaurus Property
CL317017
Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Seconday cause of death
Description

Secondaycauseofdeath

Data type

text

Seconday cause of death
Description

Secondaycauseofdeath

Data type

text

Seconday cause of death
Description

Secondaycauseofdeath

Data type

text

Seconday cause of death
Description

Secondaycauseofdeath

Data type

text

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1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient death
DeathDocumentedDate
Item
Record date of death
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
AutopsyPerformedInd-3
Item
Was an autopsy performed
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25153 (NCI Thesaurus ObjectClass)
C0004398 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
Item Group
Enter Appropriate Cause Of Death Code Below. List In Order Of Decreasing Severity
Item
Primary cause of death
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C25251 (NCI Thesaurus ValueDomain)
C0205225 (UMLS 2011AA ValueDomain)
CL.1
Code List
Primary cause of death
CL Item
Graft rejection or failure (Graft rejection or failure)
CL Item
Autology recovery (Autology recovery)
CL Item
Rejection (Rejection)
CL Item
Bacterial infection (Bacterial infection)
CL Item
Fungal infection (Fungal infection)
CL Item
Viral infection (Viral infection)
CL Item
Protozoal infection (Protozoal infection)
CL Item
Other, specify below (Other, specify below)
CL Item
Organism not identified (Organism not identified)
CL Item
Viral, CMV (interstitial pneumonia) (Viral, CMV (interstitial pneumonia))
CL Item
Viral, Other (interstitial pneumonia) (Viral, Other (interstitial pneumonia))
CL Item
Pneumocystic (interstitial pneumonia) (Pneumocystic (interstitial pneumonia))
CL Item
Other, specify below (Other, specify below)
CL Item
Idiopathic (interstitial pneumonia) (Idiopathic (interstitial pneumonia))
CL Item
Adult respiratory distress syndrome (Adult respiratory distress syndrome)
CL Item
Acute GVHD (Acute GVHD)
CL Item
Chronic GVHD (Chronic GVHD)
CL Item
Recurrence or persistence of leukemia/malignancy/MDS (Recurrence or persistence of leukemia/malignancy/MDS)
CL Item
Due To This Disease (Persistent disease)
CL Item
Liver failure (not due to GVHD or infection) (Liver failure (not due to GVHD or infection))
CL Item
Cardiac (cardiomyopathy) failure (not due to GVHD or infection) (Cardiac (cardiomyopathy) failure (not due to GVHD or infection))
CL Item
Pulmonary failure (not due to GVHD or infection) (Pulmonary failure (not due to GVHD or infection))
CL Item
CNS failure (not due to GVHD or infection) (CNS failure (not due to GVHD or infection))
CL Item
Renal failure (not due to GVHD or infection) (Renal failure (not due to GVHD or infection))
CL Item
Other failure (not due to GVHD or infection), specify below (Other failure (not due to GVHD or infection), specify below)
CL Item
Multiple organ failure, specify below (Multiple organ failure, specify below)
CL Item
Secondary graft failure (Secondary graft failure)
CL Item
Due To Second Primary Or Other Malignancy (Secondary malignancy)
CL Item
EBV (EBV)
CL Item
Other, specify below (Other, specify below)
CL Item
Pulmonary hemorrhage (Pulmonary hemorrhage)
CL Item
Intracranial hemorrhage (Intracranial hemorrhage)
CL Item
Gastrointestinal hemorrhage (Gastrointestinal hemorrhage)
CL Item
Hemorrhage, not specified (Hemorrhage, not specified)
CL Item
Other hemorrhage, specify below (Other hemorrhage, specify below)
CL Item
Thromboembolic (Thromboembolic)
CL Item
Disseminated intravascular coagulation (Disseminated intravascular coagulation)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Thrombotic thrombocytopenic purpura (Thrombotic thrombocytopenic purpura)
CL Item
Vascular not specified (Vascular not specified)
CL Item
Other vascular, specify below (Other vascular, specify below)
CL Item
Accidental death (Accidental death)
DeathContributingSymptomSpecify
Item
Other, specify below
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL317017 (NCI Metathesaurus Property)
DeathContributingSymptomSpecify
Item
Other, specify below
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL317017 (NCI Metathesaurus Property)
DeathContributingSymptomSpecify
Item
Other, specify below
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL317017 (NCI Metathesaurus Property)
DeathContributingSymptomSpecify
Item
Other, specify below
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL317017 (NCI Metathesaurus Property)
DeathContributingSymptomSpecify
Item
Other, specify below
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL317017 (NCI Metathesaurus Property)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
Item
Seconday cause of death
text
CL.2
Code List
Seconday cause of death
CL Item
Graft rejection or failure (Graft rejection or failure)
CL Item
Autology recovery (Autology recovery)
CL Item
Rejection (Rejection)
CL Item
Bacterial infection (Bacterial infection)
CL Item
Fungal infection (Fungal infection)
CL Item
Viral infection (Viral infection)
CL Item
Protozoal infection (Protozoal infection)
CL Item
Other, specify below (Other, specify below)
CL Item
Organism not identified (Organism not identified)
CL Item
Viral, CMV (interstitial pneumonia) (Viral, CMV (interstitial pneumonia))
CL Item
Viral, Other (interstitial pneumonia) (Viral, Other (interstitial pneumonia))
CL Item
Pneumocystic (interstitial pneumonia) (Pneumocystic (interstitial pneumonia))
CL Item
Other, specify below (Other, specify below)
CL Item
Idiopathic (interstitial pneumonia) (Idiopathic (interstitial pneumonia))
CL Item
Adult respiratory distress syndrome (Adult respiratory distress syndrome)
CL Item
Acute GVHD (Acute GVHD)
CL Item
Chronic GVHD (Chronic GVHD)
CL Item
Recurrence or persistence of leukemia/malignancy/MDS (Recurrence or persistence of leukemia/malignancy/MDS)
CL Item
Persistent disease (Persistent disease)
CL Item
Liver failure (not due to GVHD or infection) (Liver failure (not due to GVHD or infection))
CL Item
Cardiac (cardiomyopathy) failure (not due to GVHD or infection) (Cardiac (cardiomyopathy) failure (not due to GVHD or infection))
CL Item
Pulmonary failure (not due to GVHD or infection) (Pulmonary failure (not due to GVHD or infection))
CL Item
CNS failure (not due to GVHD or infection) (CNS failure (not due to GVHD or infection))
CL Item
Renal failure (not due to GVHD or infection) (Renal failure (not due to GVHD or infection))
CL Item
Other failure (not due to GVHD or infection), specify below (Other failure (not due to GVHD or infection), specify below)
CL Item
Multiple organ failure, specify below (Multiple organ failure, specify below)
CL Item
Secondary graft failure (Secondary graft failure)
CL Item
Secondary malignancy (Secondary malignancy)
CL Item
EBV (EBV)
CL Item
Other, specify below (Other, specify below)
CL Item
Pulmonary hemorrhage (Pulmonary hemorrhage)
CL Item
Intracranial hemorrhage (Intracranial hemorrhage)
CL Item
Gastrointestinal hemorrhage (Gastrointestinal hemorrhage)
CL Item
Hemorrhage, not specified (Hemorrhage, not specified)
CL Item
Other hemorrhage, specify below (Other hemorrhage, specify below)
CL Item
Thromboembolic (Thromboembolic)
CL Item
Disseminated intravascular coagulation (Disseminated intravascular coagulation)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Thrombotic thrombocytopenic purpura (Thrombotic thrombocytopenic purpura)
CL Item
Vascular not specified (Vascular not specified)
CL Item
Other vascular, specify below (Other vascular, specify below)
CL Item
Accidental death (Accidental death)
Item
Seconday cause of death
text
CL.3
Code List
Seconday cause of death
CL Item
Graft rejection or failure (Graft rejection or failure)
CL Item
Autology recovery (Autology recovery)
CL Item
Rejection (Rejection)
CL Item
Bacterial infection (Bacterial infection)
CL Item
Fungal infection (Fungal infection)
CL Item
Viral infection (Viral infection)
CL Item
Protozoal infection (Protozoal infection)
CL Item
Other, specify below (Other, specify below)
CL Item
Organism not identified (Organism not identified)
CL Item
Viral, CMV (interstitial pneumonia) (Viral, CMV (interstitial pneumonia))
CL Item
Viral, Other (interstitial pneumonia) (Viral, Other (interstitial pneumonia))
CL Item
Pneumocystic (interstitial pneumonia) (Pneumocystic (interstitial pneumonia))
CL Item
Other, specify below (Other, specify below)
CL Item
Idiopathic (interstitial pneumonia) (Idiopathic (interstitial pneumonia))
CL Item
Adult respiratory distress syndrome (Adult respiratory distress syndrome)
CL Item
Acute GVHD (Acute GVHD)
CL Item
Chronic GVHD (Chronic GVHD)
CL Item
Recurrence or persistence of leukemia/malignancy/MDS (Recurrence or persistence of leukemia/malignancy/MDS)
CL Item
Persistent disease (Persistent disease)
CL Item
Liver failure (not due to GVHD or infection) (Liver failure (not due to GVHD or infection))
CL Item
Cardiac (cardiomyopathy) failure (not due to GVHD or infection) (Cardiac (cardiomyopathy) failure (not due to GVHD or infection))
CL Item
Pulmonary failure (not due to GVHD or infection) (Pulmonary failure (not due to GVHD or infection))
CL Item
CNS failure (not due to GVHD or infection) (CNS failure (not due to GVHD or infection))
CL Item
Renal failure (not due to GVHD or infection) (Renal failure (not due to GVHD or infection))
CL Item
Other failure (not due to GVHD or infection), specify below (Other failure (not due to GVHD or infection), specify below)
CL Item
Multiple organ failure, specify below (Multiple organ failure, specify below)
CL Item
Secondary graft failure (Secondary graft failure)
CL Item
Secondary malignancy (Secondary malignancy)
CL Item
EBV (EBV)
CL Item
Other, specify below (Other, specify below)
CL Item
Pulmonary hemorrhage (Pulmonary hemorrhage)
CL Item
Intracranial hemorrhage (Intracranial hemorrhage)
CL Item
Gastrointestinal hemorrhage (Gastrointestinal hemorrhage)
CL Item
Hemorrhage, not specified (Hemorrhage, not specified)
CL Item
Other hemorrhage, specify below (Other hemorrhage, specify below)
CL Item
Thromboembolic (Thromboembolic)
CL Item
Disseminated intravascular coagulation (Disseminated intravascular coagulation)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Thrombotic thrombocytopenic purpura (Thrombotic thrombocytopenic purpura)
CL Item
Vascular not specified (Vascular not specified)
CL Item
Other vascular, specify below (Other vascular, specify below)
CL Item
Accidental death (Accidental death)
Item
Seconday cause of death
text
CL.4
Code List
Seconday cause of death
CL Item
Graft rejection or failure (Graft rejection or failure)
CL Item
Autology recovery (Autology recovery)
CL Item
Rejection (Rejection)
CL Item
Bacterial infection (Bacterial infection)
CL Item
Fungal infection (Fungal infection)
CL Item
Viral infection (Viral infection)
CL Item
Protozoal infection (Protozoal infection)
CL Item
Other, specify below (Other, specify below)
CL Item
Organism not identified (Organism not identified)
CL Item
Viral, CMV (interstitial pneumonia) (Viral, CMV (interstitial pneumonia))
CL Item
Viral, Other (interstitial pneumonia) (Viral, Other (interstitial pneumonia))
CL Item
Pneumocystic (interstitial pneumonia) (Pneumocystic (interstitial pneumonia))
CL Item
Other, specify below (Other, specify below)
CL Item
Idiopathic (interstitial pneumonia) (Idiopathic (interstitial pneumonia))
CL Item
Adult respiratory distress syndrome (Adult respiratory distress syndrome)
CL Item
Acute GVHD (Acute GVHD)
CL Item
Chronic GVHD (Chronic GVHD)
CL Item
Recurrence or persistence of leukemia/malignancy/MDS (Recurrence or persistence of leukemia/malignancy/MDS)
CL Item
Persistent disease (Persistent disease)
CL Item
Liver failure (not due to GVHD or infection) (Liver failure (not due to GVHD or infection))
CL Item
Cardiac (cardiomyopathy) failure (not due to GVHD or infection) (Cardiac (cardiomyopathy) failure (not due to GVHD or infection))
CL Item
Pulmonary failure (not due to GVHD or infection) (Pulmonary failure (not due to GVHD or infection))
CL Item
CNS failure (not due to GVHD or infection) (CNS failure (not due to GVHD or infection))
CL Item
Renal failure (not due to GVHD or infection) (Renal failure (not due to GVHD or infection))
CL Item
Other failure (not due to GVHD or infection), specify below (Other failure (not due to GVHD or infection), specify below)
CL Item
Multiple organ failure, specify below (Multiple organ failure, specify below)
CL Item
Secondary graft failure (Secondary graft failure)
CL Item
Secondary malignancy (Secondary malignancy)
CL Item
EBV (EBV)
CL Item
Other, specify below (Other, specify below)
CL Item
Pulmonary hemorrhage (Pulmonary hemorrhage)
CL Item
Intracranial hemorrhage (Intracranial hemorrhage)
CL Item
Gastrointestinal hemorrhage (Gastrointestinal hemorrhage)
CL Item
Hemorrhage, not specified (Hemorrhage, not specified)
CL Item
Other hemorrhage, specify below (Other hemorrhage, specify below)
CL Item
Thromboembolic (Thromboembolic)
CL Item
Disseminated intravascular coagulation (Disseminated intravascular coagulation)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Thrombotic thrombocytopenic purpura (Thrombotic thrombocytopenic purpura)
CL Item
Vascular not specified (Vascular not specified)
CL Item
Other vascular, specify below (Other vascular, specify below)
CL Item
Accidental death (Accidental death)
Item
Seconday cause of death
text
CL.5
Code List
Seconday cause of death
CL Item
Graft rejection or failure (Graft rejection or failure)
CL Item
Autology recovery (Autology recovery)
CL Item
Rejection (Rejection)
CL Item
Bacterial infection (Bacterial infection)
CL Item
Fungal infection (Fungal infection)
CL Item
Viral infection (Viral infection)
CL Item
Protozoal infection (Protozoal infection)
CL Item
Other, specify below (Other, specify below)
CL Item
Organism not identified (Organism not identified)
CL Item
Viral, CMV (interstitial pneumonia) (Viral, CMV (interstitial pneumonia))
CL Item
Viral, Other (interstitial pneumonia) (Viral, Other (interstitial pneumonia))
CL Item
Pneumocystic (interstitial pneumonia) (Pneumocystic (interstitial pneumonia))
CL Item
Other, specify below (Other, specify below)
CL Item
Idiopathic (interstitial pneumonia) (Idiopathic (interstitial pneumonia))
CL Item
Adult respiratory distress syndrome (Adult respiratory distress syndrome)
CL Item
Acute GVHD (Acute GVHD)
CL Item
Chronic GVHD (Chronic GVHD)
CL Item
Recurrence or persistence of leukemia/malignancy/MDS (Recurrence or persistence of leukemia/malignancy/MDS)
CL Item
Persistent disease (Persistent disease)
CL Item
Liver failure (not due to GVHD or infection) (Liver failure (not due to GVHD or infection))
CL Item
Cardiac (cardiomyopathy) failure (not due to GVHD or infection) (Cardiac (cardiomyopathy) failure (not due to GVHD or infection))
CL Item
Pulmonary failure (not due to GVHD or infection) (Pulmonary failure (not due to GVHD or infection))
CL Item
CNS failure (not due to GVHD or infection) (CNS failure (not due to GVHD or infection))
CL Item
Renal failure (not due to GVHD or infection) (Renal failure (not due to GVHD or infection))
CL Item
Other failure (not due to GVHD or infection), specify below (Other failure (not due to GVHD or infection), specify below)
CL Item
Multiple organ failure, specify below (Multiple organ failure, specify below)
CL Item
Secondary graft failure (Secondary graft failure)
CL Item
Secondary malignancy (Secondary malignancy)
CL Item
EBV (EBV)
CL Item
Other, specify below (Other, specify below)
CL Item
Pulmonary hemorrhage (Pulmonary hemorrhage)
CL Item
Intracranial hemorrhage (Intracranial hemorrhage)
CL Item
Gastrointestinal hemorrhage (Gastrointestinal hemorrhage)
CL Item
Hemorrhage, not specified (Hemorrhage, not specified)
CL Item
Other hemorrhage, specify below (Other hemorrhage, specify below)
CL Item
Thromboembolic (Thromboembolic)
CL Item
Disseminated intravascular coagulation (Disseminated intravascular coagulation)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Thrombotic thrombocytopenic purpura (Thrombotic thrombocytopenic purpura)
CL Item
Vascular not specified (Vascular not specified)
CL Item
Other vascular, specify below (Other vascular, specify below)
CL Item
Accidental death (Accidental death)
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