ID

1599

Description

GOG-0249 Comorbid Illness Reporting Form Pelvic Radiation Therapy or Vaginal Implant Radiation Therapy, Paclitaxel, and Carboplatin in Treating Patients With High-Risk Stage I or Stage II Endometrial Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4FF32E53-FBDB-394B-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4FF32E53-FBDB-394B-E044-0003BA3F9857

Keywords

  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

September 19, 2012

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :


    No comments

    In order to download data models you must be logged in. Please log in or register for free.

    Endometrial Cancer NCT00807768 On-Study - GOG-0249 Comorbid Illness Reporting Form - 2760082v1.0

    No Instruction available.

    1. StudyEvent: GOG-0249 Comorbid Illness Reporting Form
      1. No Instruction available.
    Header Module
    Description

    Header Module

    Date form originally completed (m d y)
    Description

    FormOriginalCompleteDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS 2011AA ObjectClass
    C0376315
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus Property
    C25604
    UMLS 2011AA Property
    C0205313
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    Date form amended (m d y)
    Description

    FormAmendedCompleteDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS 2011AA ObjectClass
    C0376315
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    Person amending form, last name
    Description

    ResponsiblePersonReportingChangeLastName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Initials (first, middle, last)
    Description

    PatientInitialsName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25536
    UMLS 2011AA Property
    C1555582
    Patient Study ID
    Description

    PatientGynecologicOncologyGroupIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25521
    UMLS 2011AA Property
    C1512288
    Person Completing Form, Last Name
    Description

    ResponsiblePersonLastName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25551
    UMLS 2011AA Property
    C1517741
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    Personal Medical History
    Description

    Personal Medical History

    Current Medical Conditions
    Description

    PatientMedicalConditionCurrentType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25261
    UMLS 2011AA Property
    C0205476
    NCI Thesaurus Property
    C25457
    UMLS 2011AA Property
    C0348080
    History of comorbid condition
    Description

    PatientPre-ExistingConditionInd-3

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Metathesaurus Property
    CL232826
    Is the patient currently taking medication for this illness or has the patient had a surgical intervention for this illness within the last 12 months
    Description

    SurgicalProcedureMedicationPriorMedicalConditionReceivedInd-3

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus ObjectClass
    C459
    UMLS 2011AA ObjectClass
    C0013227
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus Property
    C25639
    UMLS 2011AA Property
    C1514756
    NCI Thesaurus Property
    C25261
    UMLS 2011AA Property
    C0205476
    NCI Thesaurus Property
    C25457
    UMLS 2011AA Property
    C0348080
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Comments
    Description

    Comments

    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

    Similar models

    No Instruction available.

    1. StudyEvent: GOG-0249 Comorbid Illness Reporting Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header Module
    FormOriginalCompleteDate
    Item
    Date form originally completed (m d y)
    date
    C19464 (NCI Thesaurus ObjectClass)
    C0376315 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25604 (NCI Thesaurus Property)
    C0205313 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    FormAmendedCompleteDate
    Item
    Date form amended (m d y)
    date
    C19464 (NCI Thesaurus ObjectClass)
    C0376315 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    ResponsiblePersonReportingChangeLastName
    Item
    Person amending form, last name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientInitialsName
    Item
    Patient Initials (first, middle, last)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    PatientGynecologicOncologyGroupIdentifierNumber
    Item
    Patient Study ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25521 (NCI Thesaurus Property)
    C1512288 (UMLS 2011AA Property)
    ResponsiblePersonLastName
    Item
    Person Completing Form, Last Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus Property)
    C1517741 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    Item Group
    Personal Medical History
    Item
    Current Medical Conditions
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25261 (NCI Thesaurus Property)
    C0205476 (UMLS 2011AA Property)
    C25457 (NCI Thesaurus Property)
    C0348080 (UMLS 2011AA Property)
    Code List
    Current Medical Conditions
    CL Item
    Hypertension (hypertension)
    C3117 (NCI Thesaurus)
    C0020538 (UMLS 2011AA)
    CL Item
    Diabetes (diabetes)
    CL Item
    Coronary Artery Disease (Coronary artery disease)
    CL Item
    Angina (Angina)
    C51221 (NCI Thesaurus)
    C0002962 (UMLS 2011AA)
    CL Item
    Myocardial Infarction (Myocardial Infarction)
    C27996 (NCI Thesaurus)
    C0027051 (UMLS 2011AA)
    CL Item
    Peripheral Vascular Disease (peripheral vascular disease)
    CL Item
    Cerebral Vascular Accident (Cerebral vascular accident)
    CL Item
    Transient Ischemic Attack (Transient Ischemic Attack)
    CL Item
    Waist Circumference >= 35 Inches (Waist circumference >= 35 inches)
    CL Item
    Drug Treatment For Increasing Triglycerides (Drug treatment for increasing triglycerides)
    CL Item
    Drug Treatment For Decreasing Hdl-c Level (Drug treatment for decreasing HDL-C level)
    CL Item
    Drug Treatment For Hypertension (Drug treatment for hypertension)
    CL Item
    Drug Treatment For Increasing Glucose Level (Drug treatment for increasing glucose level)
    Item
    History of comorbid condition
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    CL232826 (NCI Metathesaurus Property)
    Code List
    History of comorbid condition
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Is the patient currently taking medication for this illness or has the patient had a surgical intervention for this illness within the last 12 months
    text
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C459 (NCI Thesaurus ObjectClass)
    C0013227 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C25639 (NCI Thesaurus Property)
    C1514756 (UMLS 2011AA Property)
    C25261 (NCI Thesaurus Property)
    C0205476 (UMLS 2011AA Property)
    C25457 (NCI Thesaurus Property)
    C0348080 (UMLS 2011AA Property)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    Code List
    Is the patient currently taking medication for this illness or has the patient had a surgical intervention for this illness within the last 12 months
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item Group
    Comments
    ResearchCommentsText
    Item
    COMMENTS
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial