ID

1449

Description

The Division of Cancer Prevention's screening case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=516F6F73-F6A7-27F0-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=516F6F73-F6A7-27F0-E044-0003BA3F9857

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

August 27, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Eligibility - Screening - 2762748v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Screening
    1. No Instruction available.
Screening
Description

Screening

DCP Protocol #
Description

ProtocolNCIIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C19202
UMLS 2011AA Property
C1513882
Institution Code
Description

NationalCancerInstituteInstituteCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant ID
Description

ParticipantIdentifier

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25364
UMLS 2011AA ValueDomain
C0600091
Visit Type
Description

VisitTypeText

Data type

text

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Visit Date
Description

VisitDate

Data type

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Screening
Description

Screening

Date Screening Informed Consent Signed
Description

ScreeningInformedConsentSignedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C48261
UMLS 2011AA ObjectClass
C1710032
NCI Thesaurus ObjectClass
C16735
UMLS 2011AA ObjectClass
C0021430
NCI Thesaurus Property
C25679
Not Obtained (If the screening date is not applicable check box.)
Description

NotObtainedIndicator

Data type

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Metathesaurus ObjectClass
CL310460
NCI Metathesaurus ObjectClass
CL052458
NCI Metathesaurus ValueDomain
C0021212
Not Obtained (If the screening date is not applicable check box.)
Description

NotObtainedIndicator

Data type

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Metathesaurus ObjectClass
CL310460
NCI Metathesaurus ObjectClass
CL052458
NCI Metathesaurus ValueDomain
C0021212
Screening Date
Description

ScreenDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C48261
UMLS 2011AA Property
C1710032
NCI Thesaurus ObjectClass
C15207
Is the participant a screen failure? (If the participant is a screen failure, please select the primary reason for the screen failure.)
Description

ProtocolScreenIndicator

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C48261
UMLS 2011AA Property
C1710032
NCI Thesaurus ObjectClass
C15207
If yes, specify primary reason for screen failure (Select the primary reason for the screen failure.)
Description

ProtocolScreenFailureReasonType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C48261
UMLS 2011AA Property
C1710032
NCI Thesaurus ObjectClass
C15207
Other, Specify (Enter the free text for the primary reason for the screen failure.)
Description

OtherSpecifyText

Data type

text

Alias
NCI Thesaurus Property
C25685
UMLS 2011AA Property
C1521902
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus Property
C25638
UMLS 2011AA Property
C0392360
Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Who referred participant?
Description

PatientReferralSourceName

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25683
UMLS 2011AA Property
C0449416
NCI Thesaurus Property
C52582
UMLS 2011AA Property
C0034927
NCI Thesaurus ValueDomain
C25683
UMLS 2011AA ValueDomain
C0449416
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus ValueDomain
C52582
UMLS 2011AA ValueDomain
C0034927
Other, specify
Description

PatientReferralSourceOtherSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25683
UMLS 2011AA Property
C0449416
NCI Thesaurus Property
C52582
UMLS 2011AA Property
C0034927
How did participant find out about the study?
Description

ParticipantDiscoverStudySourceName

Data type

text

Alias
NCI Thesaurus ObjectClass
C29867
UMLS 2011AA ObjectClass
C0679646
NCI Thesaurus Property
C63536
UMLS 2011AA Property
C2603343
NCI Thesaurus Property
C62262
UMLS 2011AA Property
C1880355
NCI Thesaurus ValueDomain
C25683
UMLS 2011AA ValueDomain
C0449416
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus ValueDomain
C62262
UMLS 2011AA ValueDomain
C1880355
Other, specify
Description

ParticipantDiscoverStudyOtherSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C29867
UMLS 2011AA ObjectClass
C0679646
NCI Thesaurus Property
C63536
UMLS 2011AA Property
C2603343
NCI Thesaurus Property
C62262
UMLS 2011AA Property
C1880355
Dcp Template Footer
Description

Dcp Template Footer

Protocol Title
Description

ProtocolTitleName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C42774
UMLS 2011AA Property
C1705823
Protocol Version
Description

ProtocolVersion

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Protocol Version
Description

ProtocolVersion

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Protocol Date
Description

ProtocolVersionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25367
Page #
Description

PageNumber

Data type

double

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Metathesaurus ObjectClass
C0439643
Total Page Number
Description

CaseReportFormTotalPageNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus Property
C25304
UMLS 2011AA Property
C0439810
NCI Thesaurus Property
C42783
UMLS 2011AA Property
C1704732
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
DCP Template Version
Description

DCPTemplateVersionText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Metathesaurus ObjectClass
C0728990
NCI Thesaurus Property
C25714
UMLS 2011AA Property
C0333052
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Screening
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Screening
ProtocolNCIIdentifierNumber
Item
DCP Protocol #
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C19202 (NCI Thesaurus Property)
C1513882 (UMLS 2011AA Property)
NationalCancerInstituteInstituteCode
Item
Institution Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ParticipantIdentifier
Item
Participant ID
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
VisitTypeText
Item
Visit Type
text
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
VisitDate
Item
Visit Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
Item Group
Screening
ScreeningInformedConsentSignedDate
Item
Date Screening Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C48261 (NCI Thesaurus ObjectClass)
C1710032 (UMLS 2011AA ObjectClass)
C16735 (NCI Thesaurus ObjectClass)
C0021430 (UMLS 2011AA ObjectClass)
C25679 (NCI Thesaurus Property)
Item
Not Obtained (If the screening date is not applicable check box.)
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
CL310460 (NCI Metathesaurus ObjectClass)
CL052458 (NCI Metathesaurus ObjectClass)
C0021212 (NCI Metathesaurus ValueDomain)
CL.2
Code List
Not Obtained (If the screening date is not applicable check box.)
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
Item
Not Obtained (If the screening date is not applicable check box.)
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
CL310460 (NCI Metathesaurus ObjectClass)
CL052458 (NCI Metathesaurus ObjectClass)
C0021212 (NCI Metathesaurus ValueDomain)
CL.2
Code List
Not Obtained (If the screening date is not applicable check box.)
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
ScreenDate
Item
Screening Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C48261 (NCI Thesaurus Property)
C1710032 (UMLS 2011AA Property)
C15207 (NCI Thesaurus ObjectClass)
Item
Is the participant a screen failure? (If the participant is a screen failure, please select the primary reason for the screen failure.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C48261 (NCI Thesaurus Property)
C1710032 (UMLS 2011AA Property)
C15207 (NCI Thesaurus ObjectClass)
CL.3
Code List
Is the participant a screen failure? (If the participant is a screen failure, please select the primary reason for the screen failure.)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If yes, specify primary reason for screen failure (Select the primary reason for the screen failure.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C48261 (NCI Thesaurus Property)
C1710032 (UMLS 2011AA Property)
C15207 (NCI Thesaurus ObjectClass)
CL.4
Code List
If yes, specify primary reason for screen failure (Select the primary reason for the screen failure.)
CL Item
Did Not Meet Eligibility Criteria, Specify (Did not meet eligibility criteria, specify)
CL Item
Investigator Decision (Investigator decision)
CL Item
Other, Specify (Other, specify)
CL Item
Participant Decision (Participant Decision)
OtherSpecifyText
Item
Other, Specify (Enter the free text for the primary reason for the screen failure.)
text
C25685 (NCI Thesaurus Property)
C1521902 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25638 (NCI Thesaurus Property)
C0392360 (UMLS 2011AA Property)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
Item
Who referred participant?
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25683 (NCI Thesaurus Property)
C0449416 (UMLS 2011AA Property)
C52582 (NCI Thesaurus Property)
C0034927 (UMLS 2011AA Property)
C25683 (NCI Thesaurus ValueDomain)
C0449416 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C52582 (NCI Thesaurus ValueDomain)
C0034927 (UMLS 2011AA ValueDomain)
CL.5
Code List
Who referred participant?
CL Item
Physician (Physician)
C25741 (NCI Thesaurus)
C0031831 (UMLS 2011AA)
CL Item
Health Care Provider (Health Care Provider)
C16666 (NCI Thesaurus)
C0018724 (UMLS 2011AA)
CL Item
Friend Family (Family/Friend)
C25173 (NCI Thesaurus)
C0015576 (UMLS 2011AA)
C72884 (NCI Thesaurus)
C0079382 (UMLS 2011AA)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
C0036588 (UMLS 2011AA)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientReferralSourceOtherSpecify
Item
Other, specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25683 (NCI Thesaurus Property)
C0449416 (UMLS 2011AA Property)
C52582 (NCI Thesaurus Property)
C0034927 (UMLS 2011AA Property)
Item
How did participant find out about the study?
text
C29867 (NCI Thesaurus ObjectClass)
C0679646 (UMLS 2011AA ObjectClass)
C63536 (NCI Thesaurus Property)
C2603343 (UMLS 2011AA Property)
C62262 (NCI Thesaurus Property)
C1880355 (UMLS 2011AA Property)
C25683 (NCI Thesaurus ValueDomain)
C0449416 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C62262 (NCI Thesaurus ValueDomain)
C1880355 (UMLS 2011AA ValueDomain)
CL.6
Code List
How did participant find out about the study?
CL Item
Physician (Physician)
C25741 (NCI Thesaurus)
C0031831 (UMLS 2011AA)
CL Item
Nurse (Nurse)
C20821 (NCI Thesaurus)
C0028661 (UMLS 2011AA)
CL Item
Friend Family (Family/Friend)
C25173 (NCI Thesaurus)
C0015576 (UMLS 2011AA)
C72884 (NCI Thesaurus)
C0079382 (UMLS 2011AA)
CL Item
Web Site National Cancer Institute (NCI web site)
C19202 (NCI Thesaurus)
C1513882 (UMLS 2011AA)
C67518 (NCI Thesaurus)
C2349146 (UMLS 2011AA)
CL Item
Written Material (Written material)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Specify Other (Other, specify)
C25685 (NCI Thesaurus)
C1521902 (UMLS 2011AA)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
ParticipantDiscoverStudyOtherSpecify
Item
Other, specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C29867 (NCI Thesaurus ObjectClass)
C0679646 (UMLS 2011AA ObjectClass)
C63536 (NCI Thesaurus Property)
C2603343 (UMLS 2011AA Property)
C62262 (NCI Thesaurus Property)
C1880355 (UMLS 2011AA Property)
Item Group
Dcp Template Footer
ProtocolTitleName
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)
ProtocolVersion
Item
Protocol Version
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolVersion
Item
Protocol Version
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolVersionDate
Item
Protocol Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
PageNumber
Item
Page #
double
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0439643 (NCI Metathesaurus ObjectClass)
CaseReportFormTotalPageNumber
Item
Total Page Number
text
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C42783 (NCI Thesaurus Property)
C1704732 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
DCPTemplateVersionText
Item
DCP Template Version
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C0728990 (NCI Metathesaurus ObjectClass)
C25714 (NCI Thesaurus Property)
C0333052 (UMLS 2011AA Property)
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