ID

1805

Description

AMC-052 Vaccine Administration Form Human Papillomavirus Vaccine Therapy in Treating Men With HIV-1 Infection Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=39520C70-99B3-4542-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=39520C70-99B3-4542-E044-0003BA3F9857

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/16/15 1/16/15 - Martin Dugas
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Infection NCT00513526 Treatment - AMC-052 Vaccine Administration Form - 2676576v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-052 Vaccine Administration Form
    1. No Instruction available.
Unnamed1
Description

Unnamed1

Date of vaccination (MM DD YYYY)
Description

VaccineAdministeredDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C923
UMLS 2011AA ObjectClass
C0042210
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Vaccination Site
Description

VaccineAdministeredSite

Data type

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus ObjectClass
C923
UMLS 2011AA ObjectClass
C0042210
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Amount of vaccine administered (mL)
Description

VaccineAdministeredAmount

Data type

double

Alias
NCI Thesaurus ObjectClass
C923
UMLS 2011AA ObjectClass
C0042210
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25417
Time vaccine administered (hh:mm 24 hour clock)
Description

VaccineAdministeredTime

Data type

time

Alias
NCI Thesaurus ObjectClass
C923
UMLS 2011AA ObjectClass
C0042210
NCI Thesaurus ValueDomain
C25207
UMLS 2011AA ValueDomain
C0040223
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Were there any delays in dose administration (If yes,)
Description

DoseDelayedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25477
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
Duration Delay (If dose delay was due to an adverse event, submit an Adverse Event AE form)
Description

AgentDelayedAdministrationDelayDuration

Data type

double

Alias
NCI Thesaurus Property
C25477
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus ValueDomain
C25330
UMLS 2011AA ValueDomain
C0449238
Did the participant experience syncope following vaccination
Description

VaccinationAdverseEventSyncopeInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus ObjectClass
C15346
UMLS 2011AA ObjectClass
C0042196
NCI Thesaurus Property
C35053
UMLS 2011AA Property
C0039070
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-052 Vaccine Administration Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
VaccineAdministeredDate
Item
Date of vaccination (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
C923 (NCI Thesaurus ObjectClass)
C0042210 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Vaccination Site
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C923 (NCI Thesaurus ObjectClass)
C0042210 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.1
Code List
Vaccination Site
CL Item
Dominant Arm (Dominant arm)
CL Item
Nondominant Arm (Nondominant arm)
CL Item
Right Thigh (Right thigh)
CL Item
Left Thigh (Left thigh)
VaccineAdministeredAmount
Item
Amount of vaccine administered (mL)
double
C923 (NCI Thesaurus ObjectClass)
C0042210 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25417 (NCI Thesaurus ValueDomain)
VaccineAdministeredTime
Item
Time vaccine administered (hh:mm 24 hour clock)
time
C923 (NCI Thesaurus ObjectClass)
C0042210 (UMLS 2011AA ObjectClass)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Were there any delays in dose administration (If yes,)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25477 (NCI Thesaurus Property)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
CL.2
Code List
Were there any delays in dose administration (If yes,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AgentDelayedAdministrationDelayDuration
Item
Duration Delay (If dose delay was due to an adverse event, submit an Adverse Event AE form)
double
C25477 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
Item
Did the participant experience syncope following vaccination
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C15346 (NCI Thesaurus ObjectClass)
C0042196 (UMLS 2011AA ObjectClass)
C35053 (NCI Thesaurus Property)
C0039070 (UMLS 2011AA Property)
CL.3
Code List
Did the participant experience syncope following vaccination
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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