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ID

10475

Beskrivning

AMC-046 Screen Failure Form Cidofovir in Treating HIV-Infected Patients With High-Grade Squamous Intraepithelial Lesions of the Skin Near the Anus Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3BEAAEF0-A692-3FA8-E044-0003BA3F9857 NCT00550589

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3BEAAEF0-A692-3FA8-E044-0003BA3F9857

Nyckelord

Versioner (3)
  1. 2012-08-26 2012-08-26 -
  2. 2015-05-22 2015-05-22 -
  3. 2015-06-03 2015-06-03 - Julian Varghese
Uppladdad den

3 juni 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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    AMC-046 Screen Failure Form NCT00550589

    Engelsk

    No Instruction available.

    1 Formulär  
    1. StudyEvent: AMC-046 Screen Failure Form
      1. No Instruction available.
    Biopsy/Cytology Status
    Beskrivning

    Biopsy/Cytology Status

    Anal cytology performed
    Beskrivning

    AnalCytologyPerformedIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C16491
    UMLS 2011AA ObjectClass
    C0010819
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ObjectClass
    C28048
    Most Severe Anal Cytology Result (If yes Please record the result from the cytology form)
    Beskrivning

    AnalCytologySpecimenResultType

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16491
    UMLS 2011AA ObjectClass
    C0010819
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C28048
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    High-resolution anoscopy performed
    Beskrivning

    AnalEndoscopyDiagnosticProcedurePhysicalExaminationInd-2

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16546
    UMLS 2011AA ObjectClass
    C0014245
    NCI Thesaurus ObjectClass
    C28048
    NCI Thesaurus ObjectClass
    C18020
    UMLS 2011AA ObjectClass
    C0430022
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Perianal biopsy performed
    Beskrivning

    SurroundingAnusBiopsyPerformedIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    NCI Thesaurus ObjectClass
    C43362
    UMLS 2011AA ObjectClass
    C0003461
    NCI Thesaurus ObjectClass
    C52247
    UMLS 2011AA ObjectClass
    C1282914
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Perianal biopsy result (If yes)
    Beskrivning

    SurroundingAnusBiopsyResultType

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    NCI Thesaurus ObjectClass
    C43362
    UMLS 2011AA ObjectClass
    C0003461
    NCI Thesaurus ObjectClass
    C52247
    UMLS 2011AA ObjectClass
    C1282914
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Screen Failure
    Beskrivning

    Screen Failure

    Primary reason for screen failure
    Beskrivning

    ScreeningRegistrationClinicalTrialIneligibilityReason

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C48261
    UMLS 2011AA ObjectClass
    C1710032
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C15207
    NCI Thesaurus Property
    C40412
    UMLS 2011AA Property
    C1512714
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    Other, specify
    Beskrivning

    ScreeningRegistrationClinicalTrialIneligibilitySpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C48261
    UMLS 2011AA ObjectClass
    C1710032
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C15207
    NCI Thesaurus Property
    C40412
    UMLS 2011AA Property
    C1512714
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Comments
    Beskrivning

    Comments

    Comments
    Beskrivning

    ResearchCommentsText

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
    Tillbaka till toppen

    Similar models

    No Instruction available.

    1 Formulär
    1. StudyEvent: AMC-046 Screen Failure Form
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Biopsy/Cytology Status
    Item
    Anal cytology performed
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C16491 (NCI Thesaurus ObjectClass)
    C0010819 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C28048 (NCI Thesaurus ObjectClass)
    CL.1
    Code List
    Anal cytology performed
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Most Severe Anal Cytology Result (If yes Please record the result from the cytology form)
    text
    C16491 (NCI Thesaurus ObjectClass)
    C0010819 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C28048 (NCI Thesaurus ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Most Severe Anal Cytology Result (If yes Please record the result from the cytology form)
    CL Item
    Normal (Normal)
    C14165 (NCI Thesaurus)
    C0205307 (UMLS 2011AA)
    CL Item
    Ascus (ASCUS)
    CL Item
    Low Grade Sil (Low grade SIL)
    CL Item
    Asc-h (ASC-H)
    CL Item
    High Grade Sil (High grade SIL)
    CL Item
    Unevaluable (Unevaluable)
    C62222 (NCI Thesaurus)
    C1883425 (UMLS 2011AA)
    Item
    High-resolution anoscopy performed
    text
    C16546 (NCI Thesaurus ObjectClass)
    C0014245 (UMLS 2011AA ObjectClass)
    C28048 (NCI Thesaurus ObjectClass)
    C18020 (NCI Thesaurus ObjectClass)
    C0430022 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.3
    Code List
    High-resolution anoscopy performed
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Perianal biopsy performed
    text
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    C43362 (NCI Thesaurus ObjectClass)
    C0003461 (UMLS 2011AA ObjectClass)
    C52247 (NCI Thesaurus ObjectClass)
    C1282914 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Perianal biopsy performed
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Perianal biopsy result (If yes)
    text
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    C43362 (NCI Thesaurus ObjectClass)
    C0003461 (UMLS 2011AA ObjectClass)
    C52247 (NCI Thesaurus ObjectClass)
    C1282914 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Perianal biopsy result (If yes)
    CL Item
    Normal Squamous Epithelium (Normal squamous epithelium)
    CL Item
    Squamous Metaplasia (Squamous metaplasia)
    C3237 (NCI Thesaurus)
    C0025570 (UMLS 2011AA)
    CL Item
    Condyloma (Condyloma)
    CL Item
    Flat Condyloma (Flat condyloma)
    CL Item
    Low-grade Pain (perianal Intraepithelial Neoplasia; Pain 1) (Low-grade PAIN (perianal intraepithelial neoplasia; PAIN 1))
    CL Item
    High-grade Pain (perianal Intraepithelial Neoplasia; Pain 2 Or 3) (High-grade PAIN (perianal intraepithelial neoplasia; PAIN 2 or 3))
    CL Item
    Invasive Cancer (Invasive cancer)
    CL Item
    Unevaluable (Unevaluable)
    C62222 (NCI Thesaurus)
    C1883425 (UMLS 2011AA)
    Item Group
    Screen Failure
    Item
    Primary reason for screen failure
    text
    C48261 (NCI Thesaurus ObjectClass)
    C1710032 (UMLS 2011AA ObjectClass)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C15207 (NCI Thesaurus Property)
    C40412 (NCI Thesaurus Property)
    C1512714 (UMLS 2011AA Property)
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    CL.6
    Code List
    Primary reason for screen failure
    CL Item
    Not Biopsy Proven Hsil (Not biopsy proven HSIL)
    CL Item
    Laboratory Parameters Not Met (Laboratory parameters not met)
    CL Item
    Participant Pregnant (Participant Pregnant)
    CL Item
    Plans To Start Antiretroviral Therapy Prior To Week 12 (Plans to start antiretroviral therapy prior to week 12)
    CL Item
    Cd4 Cell Count (CD4 cell count)
    CL Item
    Change In Antiretroviral Therapy Within 12 Weeks Of Enrollment (Change in antiretroviral therapy within 12 weeks of enrollment)
    CL Item
    Serious Illness Within 45 Days Prior To Entry (Serious illness within 45 days prior to entry)
    CL Item
    Participant Withdrew Consent (Participant withdrew consent)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    ScreeningRegistrationClinicalTrialIneligibilitySpecify
    Item
    Other, specify
    text
    C48261 (NCI Thesaurus ObjectClass)
    C1710032 (UMLS 2011AA ObjectClass)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C15207 (NCI Thesaurus Property)
    C40412 (NCI Thesaurus Property)
    C1512714 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
    Tillbaka till toppen 

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