ID

11608

Description

AMC-076 HPV On-Study Form (ONS) NCT01164722 Infrared Coagulator Ablation or Observation in Preventing Anal Cancer in HIV-Positive Patients With Anal Neoplasia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A80C062E-17BA-F42E-E040-BB89AD432F38

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A80C062E-17BA-F42E-E040-BB89AD432F38

Keywords

Versions (4)
  1. 5/22/15 5/22/15 -
  2. 6/3/15 6/3/15 - Julian Varghese
  3. 7/8/15 7/8/15 -
  4. 7/8/15 7/8/15 -
Uploaded on

July 8, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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AMC-076 HPV On-Study Form (ONS) NCT01164722

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-076 HPV On-Study Form (ONS)
    1. No Instruction available.
Header Module
Description

Header Module

Visit number
Description

Visit number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI-1
C1549755
HIV Status
Description

HIV Status

Date of HIV+ diagnosis (mm/dd/yyyy)
Description

HIV Diagnosis date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C14219
NCI Thesaurus Property
C15220
UMLS CUI-1
C0920550
UMLS CUI-2
C2316983
Date of AIDS diagnosis (mm/dd/yyyy)
Description

Date of AIDS diagnosis (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C15220
NCI Thesaurus ObjectClass
C2851
UMLS CUI-1
C2316983
UMLS CUI-2
C0597774
CDC HIV Risk Group
Description

HIV risk lifestyle

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C14219
NCI Thesaurus Property-2
C17102
NCI Thesaurus Property-3
C25161
NCI Thesaurus ValueDomain
C25372
UMLS CUI-1
C0425042
Other, specify
Description

Other, specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C14219
NCI Thesaurus Property-2
C17102
NCI Thesaurus Property-3
C25161
UMLS CUI-1
C0425042
Condyloma Status
Description

Condyloma Status

History of anal, perianal, or genital condyloma (If "Yes", answer the following)
Description

Condyloma Status

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus ObjectClass-2
C14226
NCI Thesaurus Property
C13348
NCI Thesaurus Property-2
C18772
NCI Thesaurus Property-3
C4054
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0302180
History of penile or genital condyloma
Description

History of penile or genital condyloma

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus ObjectClass-2
C14226
NCI Thesaurus Property
C13348
NCI Thesaurus Property-2
C12409
NCI Thesaurus Property-3
C18772
NCI Thesaurus Property-4
C2960
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0262926
UMLS CUI-2
C0302180
History of perianal condyloma
Description

History of perianal condyloma

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus ObjectClass-2
C14226
NCI Thesaurus Property
C18772
NCI Thesaurus Property-2
C52247
NCI Thesaurus Property-3
C4054
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0262926
UMLS CUI-2
C1282914
UMLS CUI-3
C0281779
History of intraanal condlyoma
Description

History of intraanal condlyoma

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus ObjectClass-2
C14226
NCI Thesaurus Property
C25234
NCI Thesaurus Property-2
C18772
NCI Thesaurus Property-3
C4054
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0281779
UMLS CUI-2
C0262926
Comments
Description

Comments

Comments
Description

Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI-1
C0282411
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-076 HPV On-Study Form (ONS)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Hospital Admission Ordinal Number
Item
Visit number
text
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI-1)
Item Group
HIV Status
HIV Diagnosis Date
Item
Date of HIV+ diagnosis (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C14219 (NCI Thesaurus ObjectClass)
C15220 (NCI Thesaurus Property)
C0920550 (UMLS CUI-1)
C2316983 (UMLS CUI-2)
AIDS Diagnosis Date
Item
Date of AIDS diagnosis (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C15220 (NCI Thesaurus Property)
C2851 (NCI Thesaurus ObjectClass)
C2316983 (UMLS CUI-1)
C0597774 (UMLS CUI-2)
Item
CDC HIV Risk Group
text
C16960 (NCI Thesaurus ObjectClass)
C14219 (NCI Thesaurus Property)
C17102 (NCI Thesaurus Property-2)
C25161 (NCI Thesaurus Property-3)
C25372 (NCI Thesaurus ValueDomain)
C0425042 (UMLS CUI-1)
CL.1
Code List
CDC HIV Risk Group
CL Item
Homosexual Or Bisexual Contact (Homosexual or bisexual contact)
C0019900 (UMLS CUI-1)
C0005639 (UMLS CUI-2)
CL Item
Heterosexual Contact (Heterosexual contact)
C0556476 (UMLS CUI-1)
CL Item
Iv Drug User (IV drug user)
C0860112 (UMLS CUI-1)
CL Item
Transfusion Recipient (Transfusion recipient)
C0005841 (UMLS CUI-1)
C1709854 (UMLS CUI-2)
CL Item
Hemophilia (Hemophiliac)
C3093 (NCI Thesaurus)
C0684275 (UMLS CUI-1)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
Patient Human Immuno deficiency Virus Risk Category Specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C14219 (NCI Thesaurus Property)
C17102 (NCI Thesaurus Property-2)
C25161 (NCI Thesaurus Property-3)
C0425042 (UMLS CUI-1)
Item Group
Condyloma Status
HPV Disease Genital Anal Condyloma Personal Medical History
Item
History of anal, perianal, or genital condyloma (If "Yes", answer the following)
boolean
C2991 (NCI Thesaurus ObjectClass)
C14226 (NCI Thesaurus ObjectClass-2)
C13348 (NCI Thesaurus Property)
C18772 (NCI Thesaurus Property-2)
C4054 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C0302180 (UMLS CUI-1)
Item
History of penile or genital condyloma
text
C2991 (NCI Thesaurus ObjectClass)
C14226 (NCI Thesaurus ObjectClass-2)
C13348 (NCI Thesaurus Property)
C12409 (NCI Thesaurus Property-2)
C18772 (NCI Thesaurus Property-3)
C2960 (NCI Thesaurus Property-4)
C25688 (NCI Thesaurus ValueDomain)
C0262926 (UMLS CUI-1)
C0302180 (UMLS CUI-2)
CL.3
Code List
History of penile or genital condyloma
CL Item
Yes, Resolved With History Of Treatment (Yes, resolved with history of treatment)
CL Item
Yes, Resolved Without Treatment (Yes, resolved without treatment)
CL Item
Active Genital Condyloma (Active genital condyloma)
CL Item
Active Penile Condyloma (Active penile condyloma)
CL Item
No History (No history)
Item
History of perianal condyloma
text
C2991 (NCI Thesaurus ObjectClass)
C14226 (NCI Thesaurus ObjectClass-2)
C18772 (NCI Thesaurus Property)
C52247 (NCI Thesaurus Property-2)
C4054 (NCI Thesaurus Property-3)
C25688 (NCI Thesaurus ValueDomain)
C0262926 (UMLS CUI-1)
C1282914 (UMLS CUI-2)
C0281779 (UMLS CUI-3)
CL.4
Code List
History of perianal condyloma
CL Item
Yes, Resolved With History Of Treatment (Yes, resolved with history of treatment)
CL Item
Yes, Resolved Without Treatment (Yes, resolved without treatment)
CL Item
Active Perianal Condyloma (Active perianal condyloma)
CL Item
No History (No history)
Item
History of intraanal condlyoma
text
C2991 (NCI Thesaurus ObjectClass)
C14226 (NCI Thesaurus ObjectClass-2)
C25234 (NCI Thesaurus Property)
C18772 (NCI Thesaurus Property-2)
C4054 (NCI Thesaurus Property-3)
C25688 (NCI Thesaurus ValueDomain)
C0281779 (UMLS CUI-1)
C0262926 (UMLS CUI-2)
CL.5
Code List
History of intraanal condlyoma
CL Item
Yes, Resolved With History Of Treatment (Yes, resolved with history of treatment)
CL Item
Yes, Resolved Without Treatment (Yes, resolved without treatment)
CL Item
Active Intraanal Condyloma (Active intraanal condyloma)
CL Item
No History (No history)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS CUI-1)
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