ID

10554

Description

AMC-047 Missed Visit Form (F35) NCT00389818 Combination Chemotherapy and Rituximab in Treating Patients With Newly Diagnosed AIDS-Related B-Cell Non-Hodgkin's Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=21D86192-7394-22F4-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=21D86192-7394-22F4-E044-0003BA3F9857

Keywords

  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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    AMC-047 Missed Visit Form (F35) NCT00389818

    No Instruction available.

    1. StudyEvent: AMC-047 Missed Visit Form (F35)
      1. No Instruction available.
    Missed Visit information
    Description

    Missed Visit information

    Visit number
    Description

    HospitalAdmissionOrdinalNumber

    Data type

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16696
    UMLS 2011AA ObjectClass
    C0019994
    NCI Thesaurus Property
    C25385
    UMLS 2011AA Property
    C0809949
    Missed Visit Date (mm/dd/yyyy)
    Description

    PatientAbsentVisitDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property-2
    C25716
    UMLS 2011AA Property-2
    C0545082
    Reason patient missed visit
    Description

    PatientAbsentVisitReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property-2
    C25716
    UMLS 2011AA Property-2
    C0545082
    Other, specify
    Description

    PatientAbsentVisitSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property-2
    C25716
    UMLS 2011AA Property-2
    C0545082
    Next visit scheduled
    Description

    PatientScheduleNextVisitInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C53286
    UMLS 2011AA Property
    C0332282
    NCI Thesaurus Property-2
    C25211
    UMLS 2011AA Property-2
    C0086960
    NCI Thesaurus Property-3
    C25716
    UMLS 2011AA Property-3
    C0545082
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Comments
    Description

    Comments

    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

    Similar models

    No Instruction available.

    1. StudyEvent: AMC-047 Missed Visit Form (F35)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Missed Visit information
    HospitalAdmissionOrdinalNumber
    Item
    Visit number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16696 (NCI Thesaurus ObjectClass)
    C0019994 (UMLS 2011AA ObjectClass)
    C25385 (NCI Thesaurus Property)
    C0809949 (UMLS 2011AA Property)
    PatientAbsentVisitDate
    Item
    Missed Visit Date (mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property-2)
    C0545082 (UMLS 2011AA Property-2)
    Item
    Reason patient missed visit
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property-2)
    C0545082 (UMLS 2011AA Property-2)
    Code List
    Reason patient missed visit
    CL Item
    Patient Had Transportation Problems (Patient had transportation problems)
    CL Item
    Health Reasons (Health reasons)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Patient Could Not Get Off Work (Patient could not get off work)
    CL Item
    Patient Decided To Discontinue Study (Patient decided to discontinue study)
    CL Item
    Patient Experienced An Adverse Event (Patient experienced an Adverse Event)
    CL Item
    Patient Forgot (Patient forgot)
    CL Item
    Patient Unable To Obtain Dependent Care (Patient unable to obtain dependent care)
    CL Item
    Patient Unhappy With Frequency Of Visits (Patient unhappy with frequency of visits)
    CL Item
    Scheduling Difficulties (Scheduling difficulties)
    PatientAbsentVisitSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property-2)
    C0545082 (UMLS 2011AA Property-2)
    PatientScheduleNextVisitInd-2
    Item
    Next visit scheduled
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C53286 (NCI Thesaurus Property)
    C0332282 (UMLS 2011AA Property)
    C25211 (NCI Thesaurus Property-2)
    C0086960 (UMLS 2011AA Property-2)
    C25716 (NCI Thesaurus Property-3)
    C0545082 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (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)

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