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ID

11504

Description

ANBL0321: Death Worksheet NCT00053326 Fenretinide in Treating Children With Recurrent or Resistant Neuroblastoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B9B55D16-FD2B-1EE8-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B9B55D16-FD2B-1EE8-E034-0003BA12F5E7

Mots-clés

Versions (4)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 09/01/2015 09/01/2015 - Martin Dugas
  4. 05/07/2015 05/07/2015 -
Téléchargé le

5 juillet 2015

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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    ANBL0321: Death Worksheet NCT00053326

    Anglais

    No Instruction available.

    1 Formulaires  
    1. StudyEvent: ANBL0321: Death Worksheet
      1. No Instruction available.
    Header
    Description

    Header

    Name
    Description

    Institution Name

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Study Number
    Description

    Protocol ID COG

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516477
    NCI Thesaurus Property
    C25364
    Study Number
    Description

    Protocol ID COG

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516477
    NCI Thesaurus Property
    C25364
    COG Number
    Description

    PatientCOGIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C39353
    UMLS 2011AA Property-2
    C1516477
    Patient Initials
    Description

    Patient Initials

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Today's date
    Description

    Form Completion Date

    Type de données

    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 worksheet entered into RDE
    Description

    DataEnteredDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C37949
    UMLS 2011AA Property
    C1521975
    Death Assessment
    Description

    Death Assessment

    Date of Death (1. Required field)
    Description

    Date last contact

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0805839
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C25461
    Cause of Death (1. Required field)
    Description

    PatientDeathReason

    Type de données

    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-2
    C28554
    UMLS 2011AA ValueDomain-2
    C0011065
    Agent [agent name]
    Description

    Agent [agent name]

    Type de données

    text

    Alias
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus ValueDomain
    C1708
    NCI Thesaurus ValueDomain-2
    C42614
    UMLS CUI-1
    C1521826
    Agent [agent name]
    Description

    Agent [agent name]

    Type de données

    text

    Alias
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus ValueDomain
    C1708
    NCI Thesaurus ValueDomain-2
    C42614
    UMLS CUI-1
    C1521826
    Other, Specify [main reason patient died]
    Description

    Cause of Death, specify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0007465
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1521902
    NCI Thesaurus Property
    C28554
    Other, Specify [main reason patient died]
    Description

    Cause of Death, specify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0007465
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1521902
    NCI Thesaurus Property
    C28554
    Which of the above causes was the main reason this patient died? (1. Required field)
    Description

    PatientDeathPrimaryReason

    Type de données

    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-2
    C28554
    UMLS 2011AA ValueDomain-2
    C0011065
    Autopsy Done? (1. Required field)
    Description

    AutopsyPerformedInd-3

    Type de données

    boolean

    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
    How were the side effects of ANBL0321 therapy related to the patient's death? (1. Required field)
    Description

    DeathClinicalTrialProtocolAttributionDeathAttributionType

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C28554
    UMLS 2011AA ObjectClass
    C0011065
    NCI Thesaurus Property
    C25320
    UMLS 2011AA Property
    C1507394
    NCI Thesaurus Property-2
    C25358
    UMLS 2011AA Property-2
    C0596130
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ValueDomain-2
    C28554
    UMLS 2011AA ValueDomain-2
    C0011065
    Comments
    Description

    Research Comments

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Ccrr Module For Anbl0321: Death Worksheet
    Description

    Ccrr Module For Anbl0321: Death Worksheet

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    Similar models

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    1 Formulaires
    1. StudyEvent: ANBL0321: Death Worksheet
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Header
    Institution Name
    Item
    Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Protocol ID COG
    Item
    Study Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516477 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Protocol ID COG
    Item
    Study Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516477 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    PatientCOGIdentifierNumber
    Item
    COG Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C39353 (NCI Thesaurus Property-2)
    C1516477 (UMLS 2011AA Property-2)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Form Completion Date
    Item
    Today's date
    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)
    DataEnteredDate
    Item
    Date worksheet entered into RDE
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C37949 (NCI Thesaurus Property)
    C1521975 (UMLS 2011AA Property)
    Item Group
    Death Assessment
    Date last contact
    Item
    Date of Death (1. Required field)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0805839 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C25461 (NCI Thesaurus Property)
    Item
    Cause of Death (1. Required field)
    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)
    C28554 (NCI Thesaurus ValueDomain-2)
    C0011065 (UMLS 2011AA ValueDomain-2)
    CL.1
    Code List
    Cause of Death (1. Required field)
    CL Item
    Due To Protocol Treatment (Fenretinide)
    CL Item
    Due To Other Cause, Specify (Other, Specify)
    CL Item
    Due To This Disease (Due to this disease)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Agent
    Item
    Agent [agent name]
    text
    C25364 (NCI Thesaurus Property)
    C1708 (NCI Thesaurus ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C42614 (NCI Thesaurus ValueDomain-2)
    C1521826 (UMLS CUI-1)
    Agent
    Item
    Agent [agent name]
    text
    C25364 (NCI Thesaurus Property)
    C1708 (NCI Thesaurus ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C42614 (NCI Thesaurus ValueDomain-2)
    C1521826 (UMLS CUI-1)
    Cause of Death, specify
    Item
    Other, Specify [main reason patient died]
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0007465 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1521902 (UMLS CUI-2)
    C28554 (NCI Thesaurus Property)
    Cause of Death, specify
    Item
    Other, Specify [main reason patient died]
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0007465 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1521902 (UMLS CUI-2)
    C28554 (NCI Thesaurus Property)
    Item
    Which of the above causes was the main reason this patient died? (1. Required field)
    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)
    C28554 (NCI Thesaurus ValueDomain-2)
    C0011065 (UMLS 2011AA ValueDomain-2)
    CL.2
    Code List
    Which of the above causes was the main reason this patient died? (1. Required field)
    CL Item
    Due To Protocol Treatment (Fenretinide)
    CL Item
    Due To Other Cause, Specify (Other, Specify)
    CL Item
    Due To This Disease (Due to this disease)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    AutopsyPerformedInd-3
    Item
    Autopsy Done? (1. Required field)
    boolean
    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
    How were the side effects of ANBL0321 therapy related to the patient's death? (1. Required field)
    text
    C28554 (NCI Thesaurus ObjectClass)
    C0011065 (UMLS 2011AA ObjectClass)
    C25320 (NCI Thesaurus Property)
    C1507394 (UMLS 2011AA Property)
    C25358 (NCI Thesaurus Property-2)
    C0596130 (UMLS 2011AA Property-2)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C28554 (NCI Thesaurus ValueDomain-2)
    C0011065 (UMLS 2011AA ValueDomain-2)
    CL.4
    Code List
    How were the side effects of ANBL0321 therapy related to the patient's death? (1. Required field)
    CL Item
    Not Related (Not related)
    C25648 (NCI Thesaurus)
    C0439849 (UMLS 2011AA)
    C25594 (NCI Thesaurus-3)
    C1518422 (UMLS 2011AA-4)
    CL Item
    Minor Contribution To Death (Minor contribution to death)
    CL Item
    Major Contribution To Death (Major contribution to death)
    CL Item
    Exclusive Cause Of Death (Exclusive cause of death)
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Item Group
    Ccrr Module For Anbl0321: Death Worksheet
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