ID

1805

Descrição

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

Palavras-chave

Versões (2)
  1. 19/09/2012 19/09/2012 -
  2. 16/01/2015 16/01/2015 - Martin Dugas
Transferido a

19 de setembro de 2012

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy
Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo
Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

Infection NCT00513526 Treatment - AMC-052 Vaccine Administration Form - 2676576v1.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: AMC-052 Vaccine Administration Form
    1. No Instruction available.
Unnamed1
Descrição

Unnamed1

Date of vaccination (MM DD YYYY)
Descrição

VaccineAdministeredDate

Tipo de dados

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
Descrição

VaccineAdministeredSite

Tipo de dados

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)
Descrição

VaccineAdministeredAmount

Tipo de dados

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)
Descrição

VaccineAdministeredTime

Tipo de dados

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,)
Descrição

DoseDelayedInd-3

Tipo de dados

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)
Descrição

AgentDelayedAdministrationDelayDuration

Tipo de dados

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
Descrição

VaccinationAdverseEventSyncopeInd-2

Tipo de dados

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
Voltar ao início da página

Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: AMC-052 Vaccine Administration Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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)
Voltar ao início da página 

Contacto

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

Ajuda

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