ID

11065

Description

Concomitant Medication Form, GOG-0212, Form CMED NCT00108745 Paclitaxel or Polyglutamate Paclitaxel or Observation in Treating Patients With Stage III or Stage IV Ovarian Epithelial or Peritoneal Cancer or Fallopian Tube Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FD45FED6-D996-72B6-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FD45FED6-D996-72B6-E034-0003BA3F9857

Keywords

Versions (4)
  1. 9/19/12 9/19/12 -
  2. 11/26/14 11/26/14 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 6/16/15 6/16/15 -
Uploaded on

June 16, 2015

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Creative Commons BY-NC 3.0 Legacy
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Concomitant Medication Form, GOG-0212, Form CMED NCT00108745

English

No Instruction available.

1 forms  
  1. StudyEvent: Concomitant Medication Form, GOG-0212, Form CMED
    1. No Instruction available.
Header Module
Description

Header Module

Date form originally completed (m d y)
Description

Form Completion Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Date form amended (m d y)
Description

Amendment date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C0680532
NCI Thesaurus Property
C25250
UMLS CUI-2
C0011008
NCI Thesaurus Property-2
C25416
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Person amending form, last name
Description

Person Amending Form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25190
UMLS CUI-2
C1547383
NCI Thesaurus Property
C25364
Patient Initials (First, Middle, Last)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Study ID
Description

Patient Study ID

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Person Completing Form, Last Name
Description

Person Completing Form Last Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass-2
C25657
UMLS CUI-2
C1301584
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25551
NCI Thesaurus ValueDomain
C25191
Participating Group Protocol Number
Description

Study Number Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Participating Group Patient ID
Description

Trial subject ID Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Page Number (of)
Description

Additional Form Page Number

Data type

text

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1706499
NCI Thesaurus ObjectClass-2
C25406
UMLS CUI-2
C1704732
NCI Thesaurus Property
C25695
UMLS CUI-3
C0237753
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ValueDomain-2
C42783
Medication Information
Description

Medication Information

Did patient receive concomitant medications while on protocol therapy?
Description

ConcomitantMedicationReceivedInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
Concomitant Medication
Description

Concomitant Medication

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2347852
NCI Thesaurus ObjectClass
C459
NCI Thesaurus Property
C25639
NCI Thesaurus ObjectClass-2
C25730
Units
Description

Agent Unit

Data type

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS CUI-1
C0450442
NCI Thesaurus Property
C25730
UMLS CUI-2
C1519795
NCI Thesaurus Property-2
C25409
NCI Thesaurus ValueDomain
C25709
Concomitant Medication Administered Dose
Description

ConcomitantMedicationAdministeredDose

Data type

float

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
NCI Thesaurus ObjectClass-2
C25730
UMLS 2011AA ObjectClass-2
C0521115
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Route
Description

Drug Administration Route

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0013153
NCI Thesaurus ObjectClass
C459
NCI Thesaurus ObjectClass-2
C25409
NCI Thesaurus Property
C25169
Agent Administered Frequency
Description

Medication frequency

Data type

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS CUI-1
C3476109
NCI Thesaurus ValueDomain
C25515
NCI Thesaurus Property
C25382
Start Date
Description

ConcomitantMedicationStartDate

Data type

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25379
UMLS 2011AA ObjectClass
C0750729
NCI Metathesaurus Property
CL219258
Date last taken
Description

ConcomitantMedicationAdministrationLastDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass-2
C25730
UMLS 2011AA ObjectClass-2
C0521115
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25551
UMLS 2011AA ValueDomain-2
C1517741
Ongoing?
Description

ConcomitantMedicationAdministrationCurrentInd-3

Data type

text

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass-2
C25730
UMLS 2011AA ObjectClass-2
C0521115
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ValueDomain-2
C25471
UMLS 2011AA ValueDomain-2
C0521116
Reason
Description

ConcomitantMedicationAdministrationReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass-2
C25730
UMLS 2011AA ObjectClass-2
C0521115
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
Comment
Description

Comment

COMMENT
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Concomitant Medication Form, GOG-0212, Form CMED
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Form Completion Date
Item
Date form originally completed (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Amendment date
Item
Date form amended (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C0680532 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Person Amending Form
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1547383 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials (First, Middle, Last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient Study ID
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Person Completing Form Last Name
Item
Person Completing Form, Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Study Number Participating Group
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Additional Form Page Number
Item
Page Number (of)
text
C19464 (NCI Thesaurus ObjectClass)
C1706499 (UMLS CUI-1)
C25406 (NCI Thesaurus ObjectClass-2)
C1704732 (UMLS CUI-2)
C25695 (NCI Thesaurus Property)
C0237753 (UMLS CUI-3)
C25337 (NCI Thesaurus ValueDomain)
C42783 (NCI Thesaurus ValueDomain-2)
Item Group
Medication Information
ConcomitantMedicationReceivedInd-2
Item
Did patient receive concomitant medications while on protocol therapy?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
Concomitant Medication
Item
Concomitant Medication
text
C25704 (NCI Thesaurus ValueDomain)
C2347852 (UMLS CUI-1)
C459 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C25730 (NCI Thesaurus ObjectClass-2)
Item
Units
text
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS CUI-1)
C25730 (NCI Thesaurus Property)
C1519795 (UMLS CUI-2)
C25409 (NCI Thesaurus Property-2)
C25709 (NCI Thesaurus ValueDomain)
CL.2
Code List
Units
CL Item
Capsules (Capsules)
CL Item
Drops (Drops)
C69442 (NCI Thesaurus)
C2347093 (UMLS 2011AA)
CL Item
Gram (Gram)
C48155 (NCI Thesaurus)
C0439208 (UMLS 2011AA)
CL Item
Microgram (Microgram)
CL Item
Microliter (Microliter)
C48153 (NCI Thesaurus)
C0439243 (UMLS 2011AA)
CL Item
Milligram (Milligram)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
CL Item
Milliliter (Milliliter)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Not Specified (Not specified)
CL Item
Ounce (Ounce)
C48519 (NCI Thesaurus)
C0439218 (UMLS 2011AA)
CL Item
Puffer (Puffer)
CL Item
Spray (Spray)
CL Item
Suppository (Suppository)
CL Item
Tablespoon (Tablespoon)
CL Item
Teaspoon (Teaspoon)
ConcomitantMedicationAdministeredDose
Item
Concomitant Medication Administered Dose
float
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Route
text
C25284 (NCI Thesaurus ValueDomain)
C0013153 (UMLS CUI-1)
C459 (NCI Thesaurus ObjectClass)
C25409 (NCI Thesaurus ObjectClass-2)
C25169 (NCI Thesaurus Property)
CL.3
Code List
Route
CL Item
Ear (Auricular)
C12394 (NCI Thesaurus)
C0013443 (UMLS 2011AA)
CL Item
Skin (Dermal)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Inhaled (Inhaled)
CL Item
Intra-articular (Intra-articular)
CL Item
Intramuscular (Intramuscular)
C27974 (NCI Thesaurus)
C0442117 (UMLS 2011AA)
C27974 (NCI Thesaurus-3)
C0442117 (UMLS 2011AA-4)
CL Item
Intranasal (Intranasal)
CL Item
Intravenous (intravenous)
X-MO-6794 (MGED)
X-MO-6794 (MGED-2)
CL Item
Not Specified (Not specified)
CL Item
Ocular (Ocular)
C0521414 (NCI Metathesaurus)
CL Item
Oral (oral)
C25311 (NCI Thesaurus)
C0442027 (UMLS 2011AA)
C25311 (NCI Thesaurus-3)
C0442027 (UMLS 2011AA-4)
CL Item
Rectal (rectal)
C25224 (NCI Thesaurus)
C0205052 (UMLS 2011AA)
CL Item
Subcutaneous (Subcutaneous)
C13353 (NCI Thesaurus)
C0443315 (UMLS 2011AA)
C13353 (NCI Thesaurus-3)
C0443315 (UMLS 2011AA-4)
CL Item
Sublingual (Sublingual)
C89785 (NCI Thesaurus)
CL Item
Vaginal (vaginal)
Item
Agent Administered Frequency
text
C1708 (NCI Thesaurus ObjectClass)
C3476109 (UMLS CUI-1)
C25515 (NCI Thesaurus ValueDomain)
C25382 (NCI Thesaurus Property)
CL.4
Code List
Agent Administered Frequency
CL Item
Am (AM)
CL Item
Daily (Daily)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
Eight Times A Day (Eight times a day)
CL Item
Four Times A Day (q.i.d) (four times a day (Q.I.D))
CL Item
Not Specified (Not specified)
CL Item
Pm/bedtime (PM/bedtime)
CL Item
Six Times A Day (Six times a day)
CL Item
Three Times A Day (t.i.d) (three times a day (T.I.D))
CL Item
Twice A Day (b.i.d) (twice a day (B.I.D))
CL Item
When Needed (When needed)
ConcomitantMedicationStartDate
Item
Start Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25379 (NCI Thesaurus ObjectClass)
C0750729 (UMLS 2011AA ObjectClass)
CL219258 (NCI Metathesaurus Property)
ConcomitantMedicationAdministrationLastDate
Item
Date last taken
date
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)
Item
Ongoing?
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ValueDomain-2)
C0521116 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
Ongoing?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Reason
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
CL.6
Code List
Reason
CL Item
Advertisement (Advertisement)
CL Item
Doctor Prescription (Doctor prescription)
CL Item
Holistic Advisement (Holistic advisement)
CL Item
New Condition (New condition)
CL Item
Non Medical Advise (Non medical advise)
CL Item
Unspecified (Not specified)
C38046 (NCI Thesaurus)
C0205370 (UMLS 2011AA)
CL Item
Own Description (Own description)
CL Item
Pre-existing Condition (Pre-existing condition)
Item Group
Comment
Research Comments
Item
COMMENT
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
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