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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

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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 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C40988 (undefined)
    UMLS 2011AA ObjectClass
    C1516308 (Case Report Form)
    NCI Thesaurus Property
    C25250 (undefined)
    UMLS 2011AA Property
    C0205197 (Complete)
    SNOMED
    255594003
    LOINC
    LA13937-0
    Checklist Number (Note: This field cannot be modified by the user.)
    Description

    ChecklistNumber

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25337 (undefined)
    UMLS 2011AA Property
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C16112 (undefined)
    UMLS 2011AA ObjectClass
    C1516637 (Clinical Trial Eligibility Criteria)
    NCI Thesaurus ValueDomain
    C49073 (undefined)
    UMLS 2011AA ValueDomain
    C1707357 (Checklist)
    LOINC
    LP200110-7
    Effective Date (Note: This field cannot be modified by the user.)
    Description

    EffectiveDate

    Data type

    date

    Alias
    NCI Thesaurus Property
    C25164 (undefined)
    UMLS 2011AA Property
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Metathesaurus ObjectClass
    CL067459 (undefined)
    Waiver Number
    Description

    WaiverNumber

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25337 (undefined)
    UMLS 2011AA Property
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C42580 (undefined)
    UMLS 2011AA ObjectClass
    C1707901 (Eligibility Waiver)
    Criterion Response (Select the patient's status relative to the eligibility inclusion criterion.)
    Description

    PatientEligibilityConfirmationCodeIndicator

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus ObjectClass
    C25171 (undefined)
    UMLS 2011AA ObjectClass
    C0013893 (Eligibility Determination)
    NCI Metathesaurus Property
    C0750484 (Confirmation)
    LOINC
    LA15290-2
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS 2011AA ValueDomain
    C0805701 (Code)
    NCI Thesaurus ValueDomain
    C25180 (undefined)
    UMLS 2011AA ValueDomain
    C1522602 (Indicator)
    NCI Thesaurus ValueDomain
    C49488 (undefined)
    UMLS 2011AA ValueDomain
    C1705108 (Yes (indicator))
    NCI Thesaurus ValueDomain
    C49487 (undefined)
    UMLS 2011AA ValueDomain
    C1298908 (no)
    SNOMED
    373067005
    NCI Thesaurus ValueDomain
    C48660 (undefined)
    UMLS 2011AA ValueDomain
    C1272460 (Not Applicable)
    SNOMED
    385432009
    LOINC
    LA4543-0
    Sequence
    Description

    QuestionDisplaySequence

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C21153 (undefined)
    UMLS 2011AA ObjectClass
    C1516588 (City of Hope Mayday Pain Resource Center Patient Pain Questionnaire)
    NCI Thesaurus Property
    C25673 (undefined)
    UMLS 2011AA Property
    C1519249 (Sequence)
    NCI Thesaurus Property
    C25485 (undefined)
    UMLS 2011AA Property
    C0870432 (Display - arrangement)
    Eligibility Waiver Reason
    Description

    EligibilityWaiverReason

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25638 (undefined)
    UMLS 2011AA Property
    C0392360 (Indication of (contextual qualifier))
    SNOMED
    230165009
    LOINC
    MTHU008319
    NCI Thesaurus ValueDomain
    C25638 (undefined)
    UMLS 2011AA ValueDomain
    C0392360 (Indication of (contextual qualifier))
    SNOMED
    230165009
    LOINC
    MTHU008319
    NCI Thesaurus ObjectClass
    C42580 (undefined)
    UMLS 2011AA ObjectClass
    C1707901 (Eligibility Waiver)
    NCI Thesaurus ValueDomain
    C42580 (undefined)
    UMLS 2011AA ValueDomain
    C1707901 (Eligibility Waiver)
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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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