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)
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)