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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

Link

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

Keywords

Versions (4)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 7/5/15 7/5/15 -
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July 5, 2015

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

    English

    No Instruction available.

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

    Header

    Name
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C1301943 (Institution name)
    SNOMED
    398321007
    NCI Thesaurus ObjectClass
    C21541 (undefined)
    NCI Thesaurus ValueDomain-2
    C21541 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    Study Number
    Description

    Protocol ID COG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C3274381 (Clinical Trial Registry Identifier)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-2
    C1516477 (Children's Oncology Group)
    NCI Thesaurus Property
    C25364 (undefined)
    Study Number
    Description

    Protocol ID COG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C3274381 (Clinical Trial Registry Identifier)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-2
    C1516477 (Children's Oncology Group)
    NCI Thesaurus Property
    C25364 (undefined)
    COG Number
    Description

    PatientCOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property-2
    C39353 (undefined)
    UMLS 2011AA Property-2
    C1516477 (Children's Oncology Group)
    Patient Initials
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C2986440 (Person Initials)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25536 (undefined)
    Today's date
    Description

    Form Completion Date

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464 (undefined)
    UMLS CUI-1
    C1549507 (Report completion date/time)
    NCI Thesaurus Property
    C25250 (undefined)
    NCI Thesaurus Property-2
    C25604 (undefined)
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    NCI Thesaurus ValueDomain-2
    C25367 (undefined)
    Date worksheet entered into RDE
    Description

    DataEnteredDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    UMLS 2011AA ObjectClass
    C1511726 (Data)
    NCI Thesaurus Property
    C37949 (undefined)
    UMLS 2011AA Property
    C1521975 (Entered)
    Death Assessment
    Description

    Death Assessment

    Date of Death (1. Required field)
    Description

    Date last contact

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS CUI-1
    C0805839 (Date last contact)
    LOINC
    MTHU010432
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus ValueDomain-2
    C25367 (undefined)
    NCI Thesaurus Property
    C25461 (undefined)
    Cause of Death (1. Required field)
    Description

    PatientDeathReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638 (undefined)
    UMLS 2011AA ValueDomain
    C0392360 (Indication of (contextual qualifier))
    SNOMED
    230165009
    LOINC
    MTHU008319
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C28554 (undefined)
    UMLS 2011AA Property
    C0011065 (Cessation of life)
    SNOMED
    419620001
    NCI Thesaurus ValueDomain-2
    C28554 (undefined)
    UMLS 2011AA ValueDomain-2
    C0011065 (Cessation of life)
    SNOMED
    419620001
    Agent [agent name]
    Description

    Agent [agent name]

    Data type

    text

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

    Agent [agent name]

    Data type

    text

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

    Cause of Death, specify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS CUI-1
    C0007465 (Cause of Death)
    SNOMED
    16100001
    LOINC
    LA10595-9
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS CUI-2
    C1521902 (To specify)
    NCI Thesaurus Property
    C28554 (undefined)
    Other, Specify [main reason patient died]
    Description

    Cause of Death, specify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS CUI-1
    C0007465 (Cause of Death)
    SNOMED
    16100001
    LOINC
    LA10595-9
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS CUI-2
    C1521902 (To specify)
    NCI Thesaurus Property
    C28554 (undefined)
    Which of the above causes was the main reason this patient died? (1. Required field)
    Description

    PatientDeathPrimaryReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638 (undefined)
    UMLS 2011AA ValueDomain
    C0392360 (Indication of (contextual qualifier))
    SNOMED
    230165009
    LOINC
    MTHU008319
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C28554 (undefined)
    UMLS 2011AA Property
    C0011065 (Cessation of life)
    SNOMED
    419620001
    NCI Thesaurus ValueDomain-2
    C28554 (undefined)
    UMLS 2011AA ValueDomain-2
    C0011065 (Cessation of life)
    SNOMED
    419620001
    Autopsy Done? (1. Required field)
    Description

    AutopsyPerformedInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS 2011AA ValueDomain
    C1512699 (Yes, No, or Unknown Response)
    NCI Thesaurus ObjectClass
    C25153 (undefined)
    UMLS 2011AA ObjectClass
    C0004398 (Autopsy)
    SNOMED
    29240004
    LOINC
    LA20097-4
    NCI Thesaurus Property
    C38000 (undefined)
    UMLS 2011AA Property
    C0884358 (Performed)
    SNOMED
    398166005
    LOINC
    LA19974-7
    How were the side effects of ANBL0321 therapy related to the patient's death? (1. Required field)
    Description

    DeathClinicalTrialProtocolAttributionDeathAttributionType

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C28554 (undefined)
    UMLS 2011AA ObjectClass
    C0011065 (Cessation of life)
    SNOMED
    419620001
    NCI Thesaurus Property
    C25320 (undefined)
    UMLS 2011AA Property
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property-2
    C25358 (undefined)
    UMLS 2011AA Property-2
    C0596130 (Attribution)
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    NCI Thesaurus ValueDomain-2
    C28554 (undefined)
    UMLS 2011AA ValueDomain-2
    C0011065 (Cessation of life)
    SNOMED
    419620001
    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS CUI-1
    C0947611 (Comment)
    LOINC
    LP72293-1
    NCI Thesaurus ObjectClass
    C15319 (undefined)
    NCI Thesaurus Property
    C25393 (undefined)
    Ccrr Module For Anbl0321: Death Worksheet
    Description

    Ccrr Module For Anbl0321: Death Worksheet

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    1 forms
    1. StudyEvent: ANBL0321: Death Worksheet
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    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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