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

  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

    No Instruction available.

    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

    Similar models

    No Instruction available.

    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)
    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)
    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)
    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)
    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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