ID

11696

Description

AE2 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF17FFED-E72C-015A-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF17FFED-E72C-015A-E034-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/28/15 7/28/15 - Julian Varghese
Uploaded on

July 28, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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AE2

English

No Instruction available.

1 forms  
Averse Events
Description

Averse Events

Date of Onset
Description

Adverse Event Onset Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2985916
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C25279
Event description
Description

AdverseEventTreatingDescriptionText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25705
UMLS 2011AA Property
C1522326
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
Segment
Description

Segment

Data type

text

Relevant Past Medical History
Description

Relevant Past Medical History

Include any relevant history, including preexisting medical conditions below
Description

PatientMedicalConditionText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25261
UMLS 2011AA Property
C0205476
NCI Thesaurus Property-2
C25457
UMLS 2011AA Property-2
C0348080
Event Summary
Description

Event Summary

Date
Description

FormSubmissionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
Date
Description

FormSubmissionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
Include clinical history of event, associated signs or symptoms, alternative etiologies being considered and medical management below
Description

Includeclinicalhistoryofevent,associatedsignsorsymptoms,alternativeetiologiesbeingconsideredandmedicalmanagementbelow

Data type

text

Initial submitter
Description

Initialsubmitter

Data type

text

Name
Description

Name

Data type

text

Authorized submitter
Description

Authorizedsubmitter

Data type

text

Name
Description

Name

Data type

text

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Similar models

No Instruction available.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Averse Events
Adverse Event Onset Date
Item
Date of Onset
date
C25164 (NCI Thesaurus ValueDomain)
C2985916 (UMLS CUI-1)
C25367 (NCI Thesaurus ValueDomain-2)
C49704 (NCI Thesaurus ObjectClass)
C25279 (NCI Thesaurus Property)
AdverseEventTreatingDescriptionText
Item
Event description
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus Property)
C1522326 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
Segment
Item
Segment
text
Item Group
Relevant Past Medical History
PatientMedicalConditionText
Item
Include any relevant history, including preexisting medical conditions below
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property-2)
C0348080 (UMLS 2011AA Property-2)
Item Group
Event Summary
FormSubmissionDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
FormSubmissionDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
Includeclinicalhistoryofevent,associatedsignsorsymptoms,alternativeetiologiesbeingconsideredandmedicalmanagementbelow
Item
Include clinical history of event, associated signs or symptoms, alternative etiologies being considered and medical management below
text
Initialsubmitter
Item
Initial submitter
text
Name
Item
Name
text
Authorizedsubmitter
Item
Authorized submitter
text
Name
Item
Name
text
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