ID

11424

Description

Concomitant Medication Form NCT00058149 A Phase III, Randomized Study of Gemcitabine (Fixed-Dose Rate Infusion) and Oxaliplatin (NSC 266046) Versus Gemcitabine (Fixed-Dose Rate Infusion) Versus Gemcitabine (30-Minute Infusion) in Pancreatic Carcinoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6277C4D-6BBD-3D79-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6277C4D-6BBD-3D79-E034-0003BA0B1A09

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

July 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Concomitant Medication Form NCT00058149

English

No Instruction available.

1 forms  
  1. StudyEvent: Concomitant Medication Form
    1. No Instruction available.
ECOG clinical trial administrative data
Description

ECOG clinical trial administrative data

ECOG Prot. No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient Seq. No.
Description

ECOGPatientID

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient?s Name
Description

Patient'sName

Data type

text

Participating Group Prot. No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID No.
Description

ParticipatingGroupPatientID

Data type

text

Step No.
Description

StepNo.

Data type

text

Group
Description

ParticipatingGroupName

Data type

text

Institution
Description

InstitutionName

Data type

text

Network
Description

Network

Data type

text

Affiliate
Description

AffiliateName

Data type

text

Are data amended? (If yes, please circle amended items in red)
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Reporting period Start Date: (M D Y)
Description

IntervalReportFromDate

Data type

date

Reporting period End Date: (M D Y)
Description

IntervalReportToDate

Data type

date

Concomitant Medication
Description

Concomitant Medication

Generic Name (Use brand or trade if generic name unknown)
Description

AgentName

Data type

text

Dose
Description

Dose

Data type

float

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
Units
Description

Units

Data type

text

other, specify
Description

other,specify

Data type

text

Alias
NCI Thesaurus ObjectClass
C25179
UMLS 2011AA ObjectClass
C0019993
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Frequency
Description

Frequency

Data type

text

Alias
NCI Thesaurus ObjectClass
C25515
UMLS 2011AA ObjectClass
C0439603
Route
Description

AgentAdminRoute

Data type

text

Start Date (Leave blank if continuing from a prior report period)
Description

AgentBeginDate

Data type

date

Is this medication continuing?
Description

Isthismedicationcontinuing?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Stop Date (Leave blank if continuing)
Description

AgentEndDate

Data type

date

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Investigator Signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Description

InvestigatorSignatureDate

Data type

date

Ccrr Module For Concomitant Medication Form
Description

Ccrr Module For Concomitant Medication Form

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Patient Initials
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
DCI Name
Description

DCIName

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Concomitant Medication Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
ECOG clinical trial administrative data
ECOGProtocolNo.
Item
ECOG Prot. No.
text
ECOGPatientID
Item
ECOG Patient Seq. No.
text
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ParticipatingGroupProtocolNo.
Item
Participating Group Prot. No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID No.
text
StepNo.
Item
Step No.
text
ParticipatingGroupName
Item
Group
text
InstitutionName
Item
Institution
text
Network
Item
Network
text
AffiliateName
Item
Affiliate
text
AmendedDataInd
Item
Are data amended? (If yes, please circle amended items in red)
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
IntervalReportFromDate
Item
Reporting period Start Date: (M D Y)
date
IntervalReportToDate
Item
Reporting period End Date: (M D Y)
date
Item Group
Concomitant Medication
AgentName
Item
Generic Name (Use brand or trade if generic name unknown)
text
Dose
Item
Dose
float
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
Item
Units
text
CL.2
Code List
Units
CL Item
capsules (caps) (capsules (caps))
CL Item
gram (gm) (gram (gm))
CL Item
drops (gtts) (drops (gtts))
CL Item
inch (inch) (inch (inch))
CL Item
kilogram (kg) (kilogram (kg))
CL Item
liter (l) (liter (l))
CL Item
microgram (mcg) (microgram (mcg))
CL Item
milliequivalent (mEq) (milliequivalent (mEq))
CL Item
milligram (mg) (milligram (mg))
CL Item
milliliter (ml) (milliliter (ml))
CL Item
ounce (oz) (ounce (oz))
CL Item
tablets (tabs) (tablets (tabs))
CL Item
tablespoon (tbsp) (tablespoon (tbsp))
CL Item
teaspoon (tsp) (teaspoon (tsp))
CL Item
unit (u) (unit (u))
CL Item
other, specify (other, specify)
other,specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Frequency
text
C25515 (NCI Thesaurus ObjectClass)
C0439603 (UMLS 2011AA ObjectClass)
CL.3
Code List
Frequency
CL Item
Immediately (stat) (immediately (Stat))
CL Item
As Needed (p.r.n) (as needed (P.R.N))
CL Item
Every Day (q.d.) (every day (Q.D.))
CL Item
Every Other Day (q.o.d.) (every other day (Q.O.D.))
CL Item
Twice A Day (b.i.d) (twice a day (B.I.D))
CL Item
Three Times A Day (t.i.d) (three times a day (T.I.D))
CL Item
Four Times A Day (q.i.d) (four times a day (Q.I.D))
CL Item
Twice A Week (b.i.w) (twice a week (B.I.W))
CL Item
Three Times A Week (t.i.w) (three times a week (T.I.W))
CL Item
Before Meals (a.c.) (before meals (A.C.))
CL Item
After Meals (p.c.) (after meals (P.C.))
CL Item
At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep (H.S.))
CL Item
Every 4 Hours (q4hr) (every 4 hours (Q4hr))
CL Item
Every 6 Hours (q6hr) (every 6 hours (Q6hr))
CL Item
Every 8 Hours (q8hr) (every 8 hours (Q8hr))
CL Item
Every 12 Hours (q12hr) (every 12 hours (Q12hr))
CL Item
Other, Specify (other, specify)
Item
Route
text
CL.4
Code List
Route
CL Item
Oral Administration Of Drug (oral (p.o.))
CL Item
subcutaneous (s.c.) (subcutaneous (s.c.))
CL Item
Intramuscular Administration Of Drug (intramuscular (i.m.))
CL Item
Intravenous Administration Of Drug (intravenous (i.v.))
CL Item
rectal (rectal)
CL Item
topical (topical)
CL Item
nasal (nasal)
CL Item
inhaled (inhaled)
CL Item
transdermal (transdermal)
CL Item
sublingual (sublingual)
CL Item
intradermal (intradermal)
CL Item
other, specify (other, specify)
AgentBeginDate
Item
Start Date (Leave blank if continuing from a prior report period)
date
Isthismedicationcontinuing?
Item
Is this medication continuing?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
AgentEndDate
Item
Stop Date (Leave blank if continuing)
date
Item Group
Comments
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Concomitant Medication Form
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
DCIName
Item
DCI Name
text
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