ID

1477

Description

The patient's status for each item of the eligibility checklist. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ACFB66E7-BD58-6D16-E040-BB89AD4363C3

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ACFB66E7-BD58-6D16-E040-BB89AD4363C3

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 7/14/17 7/14/17 - Martin Dugas
Uploaded on

August 27, 2012

DOI

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License

Creative Commons BY-NC 3.0
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Eligibility - Eligibility Checklist - 3276641v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Eligibility Checklist
    1. No Instruction available.
Eligibility Checklist
Description

Eligibility Checklist

Visit Date (Enter the date the form was completed i.e. the date information was gathered.)
Description

FormCompletionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
Checklist Number (Note: This field cannot be modified by the user.)
Description

ChecklistNumber

Data type

text

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16112
UMLS 2011AA ObjectClass
C1516637
NCI Thesaurus ValueDomain
C49073
UMLS 2011AA ValueDomain
C1707357
Effective Date (Note: This field cannot be modified by the user.)
Description

EffectiveDate

Data type

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Metathesaurus ObjectClass
CL067459
Waiver Number
Description

WaiverNumber

Data type

text

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ObjectClass
C42580
UMLS 2011AA ObjectClass
C1707901
Criterion Response (Select the patient's status relative to the eligibility inclusion criterion.)
Description

PatientEligibilityConfirmationCodeIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C25171
UMLS 2011AA ObjectClass
C0013893
NCI Metathesaurus Property
C0750484
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ValueDomain
C49488
UMLS 2011AA ValueDomain
C1705108
NCI Thesaurus ValueDomain
C49487
UMLS 2011AA ValueDomain
C1298908
NCI Thesaurus ValueDomain
C48660
UMLS 2011AA ValueDomain
C1272460
Sequence
Description

QuestionDisplaySequence

Data type

text

Alias
NCI Thesaurus ObjectClass
C21153
UMLS 2011AA ObjectClass
C1516588
NCI Thesaurus Property
C25673
UMLS 2011AA Property
C1519249
NCI Thesaurus Property
C25485
UMLS 2011AA Property
C0870432
Eligibility Waiver Reason
Description

EligibilityWaiverReason

Data type

text

Alias
NCI Thesaurus Property
C25638
UMLS 2011AA Property
C0392360
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C42580
UMLS 2011AA ObjectClass
C1707901
NCI Thesaurus ValueDomain
C42580
UMLS 2011AA ValueDomain
C1707901
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Eligibility Checklist
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Eligibility Checklist
FormCompletionDate
Item
Visit Date (Enter the date the form was completed i.e. the date information was gathered.)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
ChecklistNumber
Item
Checklist Number (Note: This field cannot be modified by the user.)
text
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16112 (NCI Thesaurus ObjectClass)
C1516637 (UMLS 2011AA ObjectClass)
C49073 (NCI Thesaurus ValueDomain)
C1707357 (UMLS 2011AA ValueDomain)
EffectiveDate
Item
Effective Date (Note: This field cannot be modified by the user.)
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CL067459 (NCI Metathesaurus ObjectClass)
WaiverNumber
Item
Waiver Number
text
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C42580 (NCI Thesaurus ObjectClass)
C1707901 (UMLS 2011AA ObjectClass)
Item
Criterion Response (Select the patient's status relative to the eligibility inclusion criterion.)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C0750484 (NCI Metathesaurus Property)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C49488 (NCI Thesaurus ValueDomain)
C1705108 (UMLS 2011AA ValueDomain)
C49487 (NCI Thesaurus ValueDomain)
C1298908 (UMLS 2011AA ValueDomain)
C48660 (NCI Thesaurus ValueDomain)
C1272460 (UMLS 2011AA ValueDomain)
CL.1
Code List
Criterion Response (Select the patient's status relative to the eligibility inclusion criterion.)
CL Item
Yes, All (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Not Applicable (X)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
QuestionDisplaySequence
Item
Sequence
text
C21153 (NCI Thesaurus ObjectClass)
C1516588 (UMLS 2011AA ObjectClass)
C25673 (NCI Thesaurus Property)
C1519249 (UMLS 2011AA Property)
C25485 (NCI Thesaurus Property)
C0870432 (UMLS 2011AA Property)
EligibilityWaiverReason
Item
Eligibility Waiver Reason
text
C25638 (NCI Thesaurus Property)
C0392360 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C42580 (NCI Thesaurus ObjectClass)
C1707901 (UMLS 2011AA ObjectClass)
C42580 (NCI Thesaurus ValueDomain)
C1707901 (UMLS 2011AA ValueDomain)
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