ID

2296

Descrição

E4A03 Thrombotic Event Form - After September 14, 2005 Lenalidomide and Dexamethasone With or Without Thalidomide in Treating Patients With Multiple Myeloma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=05DBF8A6-800B-1B35-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=05DBF8A6-800B-1B35-E044-0003BA3F9857

Palavras-chave

Versões (3)
  1. 19/09/2012 19/09/2012 -
  2. 08/01/2015 08/01/2015 - Martin Dugas
  3. 08/06/2015 08/06/2015 -
Transferido a

19 de setembro de 2012

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Multiple Myeloma and Plasma Cell Neoplasm NCT00098475 Treatment - E4A03 Thrombotic Event Form - After September 14, 2005 - 2431002v1.0

Inglês

INSTRUCTIONS: Use this form to capture the first occurrence of non-protocol anti-tumor therapy per registration step

1 Formulários  
Unnamed1
Descrição

Unnamed1

ECOG Protocol Number
Descrição

ProtocolECOGIdentifierNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
ECOG Patient ID
Descrição

PatientECOGIdentifierNumber

Tipo de dados

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
C25491
UMLS 2011AA Property
C1512162
DCI Name
Descrição

CollectedDataFormName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus ObjectClass
C25452
Registration Step
Descrição

RegistrationStepNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25646
UMLS 2011AA ObjectClass
C1514821
NCI Thesaurus Property
C16154
UMLS 2011AA Property
C1704379
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Unnamed2
Descrição

Unnamed2

ECOG Protocol Number
Descrição

ProtocolECOGIdentifierNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
Patient Initials
Descrição

PatientInitialsName

Tipo de dados

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
ECOG Patient ID
Descrição

PatientECOGIdentifierNumber

Tipo de dados

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
C25491
UMLS 2011AA Property
C1512162
Participating Group Protocol Number
Descrição

ProtocolParticipatingIdentifierNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution/Affiliate
Descrição

CombinedInstitutionName

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS 2011AA ObjectClass
C0205195
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
Participating Group Patient ID
Descrição

PatientParticipatingIdentifierNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Unnamed3
Descrição

Unnamed3

Please mark an 'X' if data have been amended
Descrição

DataAmendedText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Date data amended
Descrição

DataAmendedDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
NCI Thesaurus ValueDomain
C25367
On Treatment Report Period
Descrição

On Treatment Report Period

Treatment Evaluation Period Type
Descrição

TreatmentEvaluationPeriodType

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C15368
Unnamed 4
Descrição

Unnamed 4

Did patient recieve DVT prophylaxis
Descrição

DeepVeinThrombosisPreventionTherapyReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Start date of first (prophylactic) treatment
Descrição

DeepVeinThrombosisPreventionReceivedBeginDate

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25431
UMLS 2011AA ValueDomain
C0439659
Date of most recent (prophylactic) treatment
Descrição

DeepVeinThrombosisPreventionReceivedMostRecentDate

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25577
UMLS 2011AA ValueDomain
C1513491
Aspirin (81 mg) (Were any of the following given prior to the first thrombotic event this report period? answer no 1 or yes 2 for each of the following)
Descrição

DeepVeinThrombosisPreventionTherapyLowDoseAcetylsalicylicAcidReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C49341
UMLS 2011AA Property
C1708745
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Aspirin (325 mg)
Descrição

DeepVeinThrombosisPreventionTherapyModerateDoseAcetylsalicylicAcidReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus Property
C49342
UMLS 2011AA Property
C1709056
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Aspirin (other dose)
Descrição

DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
If other dose of Aspirin given, specify dose
Descrição

DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedDose

Tipo de dados

double

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
Coumadin
Descrição

DeepVeinThrombosisPreventionTherapyWarfarinReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C945
UMLS 2011AA Property
C0043031
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
If Coumadin given, specify dose
Descrição

DeepVeinThrombosisPreventionTherapyWarfarinReceivedDose

Tipo de dados

double

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C945
UMLS 2011AA Property
C0043031
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
Low molecular weight heparin (enoxaparin; Lovenox)
Descrição

DeepveinthrombosisPreventionTherapyLowMolecularWeightHeparinReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C2578
UMLS 2011AA Property
C0019139
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Other, specify
Descrição

DeepVeinThrombosisPreventionTherapyReceivedSpecify

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Has the patient received erythropoietin-type agents (e.g., Epogen, Procrit or Aranesp)
Descrição

ErythropoietinSupportAdministeredInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C20429
UMLS 2011AA ObjectClass
C0014822
NCI Thesaurus ObjectClass
C37902
UMLS 2011AA ObjectClass
C1521721
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Unnamed 5
Descrição

Unnamed 5

Did patient experience a thrombotic event (NOTE: Event must be reported through AdEERS and on the E4A03 Adverse Event Form)
Descrição

ThrombosisAdverseEventObservedInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus Property
C25599
UMLS 2011AA Property
C1441672
Date of thrombotic event (If yes, - List Date of thrombotic events this report period. Mark an ¿X¿ in the box on the right if not applicable.)
Descrição

ThrombosisAdverseEventObservedDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus Property
C25599
UMLS 2011AA Property
C1441672
Mark an 'X' if N/A
Descrição

DataUnknownText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C17998
UMLS 2011AA Property
C0439673
Was the patient on thrombotic prophylaxis (NOTE: If more then one thrombotic event this report period, answer question below with regards to the first thrombotic event this report period.)
Descrição

ThrombosisPreventionTherapyReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Aspirin (81 mg) (Were any of the following given prior to the first thrombotic event this report period? answer no 1 or yes 2 for each of the following)
Descrição

DeepVeinThrombosisPreventionTherapyLowDoseAcetylsalicylicAcidReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C49341
UMLS 2011AA Property
C1708745
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Aspirin (325 mg)
Descrição

DeepVeinThrombosisPreventionTherapyModerateDoseAcetylsalicylicAcidReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus Property
C49342
UMLS 2011AA Property
C1709056
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Aspirin (other dose)
Descrição

DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
If other dose of Aspirin given, specify dose
Descrição

DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedDose

Tipo de dados

double

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C287
UMLS 2011AA Property
C0004057
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
Coumadin
Descrição

DeepVeinThrombosisPreventionTherapyWarfarinReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C945
UMLS 2011AA Property
C0043031
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
If Coumadin given, specify dose
Descrição

DeepVeinThrombosisPreventionTherapyWarfarinReceivedDose

Tipo de dados

double

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C945
UMLS 2011AA Property
C0043031
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
Low molecular weight heparin (enoxaparin; Lovenox)
Descrição

DeepveinthrombosisPreventionTherapyLowMolecularWeightHeparinReceivedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C2578
UMLS 2011AA Property
C0019139
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Other, specify
Descrição

DeepVeinThrombosisPreventionTherapyReceivedSpecify

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C49343
UMLS 2011AA ObjectClass
C0149871
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C15405
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Has the patient received erythropoietin-type agents (e.g., Epogen, Procrit or Aranesp)
Descrição

ErythropoietinSupportAdministeredInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C20429
UMLS 2011AA ObjectClass
C0014822
NCI Thesaurus ObjectClass
C37902
UMLS 2011AA ObjectClass
C1521721
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Comments
Descrição

Comments

Investigator Signature
Descrição

InvestigatorSignatureText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Investigator Signature Date
Descrição

InvestigatorSignatureDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
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INSTRUCTIONS: Use this form to capture the first occurrence of non-protocol anti-tumor therapy per registration step

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Unnamed1
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientECOGIdentifierNumber
Item
ECOG Patient 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)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
CollectedDataFormName
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)
RegistrationStepNumber
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C1514821 (UMLS 2011AA ObjectClass)
C16154 (NCI Thesaurus Property)
C1704379 (UMLS 2011AA Property)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
Item Group
Unnamed2
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials
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)
PatientECOGIdentifierNumber
Item
ECOG Patient 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)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
ProtocolParticipatingIdentifierNumber
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
PatientParticipatingIdentifierNumber
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Unnamed3
DataAmendedText
Item
Please mark an 'X' if data have been amended
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
DataAmendedDate
Item
Date data amended
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
Item Group
On Treatment Report Period
Item
Treatment Evaluation Period Type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
CL.1
Code List
Treatment Evaluation Period Type
CL Item
Cycle 4 Step 1 (Cycle 4 Step 1)
CL Item
Cycle 8 Step 1 (Cycle 8 Step 1)
CL Item
Cycle 12 Step 1 (Cycle 12 Step 1)
CL Item
Cycle 4 Step 2 (Cycle 4 Step 2)
CL Item
Cycle 8 Step 2 (Cycle 8 Step 2)
CL Item
Cycle 12 Step 2 (Cycle 12 Step 2)
Item Group
Unnamed 4
Item
Did patient recieve DVT prophylaxis
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.2
Code List
Did patient recieve DVT prophylaxis
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
DeepVeinThrombosisPreventionReceivedBeginDate
Item
Start date of first (prophylactic) treatment
date
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
DeepVeinThrombosisPreventionReceivedMostRecentDate
Item
Date of most recent (prophylactic) treatment
date
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25577 (NCI Thesaurus ValueDomain)
C1513491 (UMLS 2011AA ValueDomain)
Item
Aspirin (81 mg) (Were any of the following given prior to the first thrombotic event this report period? answer no 1 or yes 2 for each of the following)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C49341 (NCI Thesaurus Property)
C1708745 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.12
Code List
Aspirin (81 mg) (Were any of the following given prior to the first thrombotic event this report period? answer no 1 or yes 2 for each of the following)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Aspirin (325 mg)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C49342 (NCI Thesaurus Property)
C1709056 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.13
Code List
Aspirin (325 mg)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Aspirin (other dose)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.14
Code List
Aspirin (other dose)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedDose
Item
If other dose of Aspirin given, specify dose
double
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
Item
Coumadin
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C945 (NCI Thesaurus Property)
C0043031 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.15
Code List
Coumadin
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Coumadin given, specify dose
double
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C945 (NCI Thesaurus Property)
C0043031 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
CL.16
Code List
If Coumadin given, specify dose
CL Item
No (No)
CL Item
Yes (Yes)
Item
Low molecular weight heparin (enoxaparin; Lovenox)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C2578 (NCI Thesaurus Property)
C0019139 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.17
Code List
Low molecular weight heparin (enoxaparin; Lovenox)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
DeepVeinThrombosisPreventionTherapyReceivedSpecify
Item
Other, specify
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Has the patient received erythropoietin-type agents (e.g., Epogen, Procrit or Aranesp)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C20429 (NCI Thesaurus ObjectClass)
C0014822 (UMLS 2011AA ObjectClass)
C37902 (NCI Thesaurus ObjectClass)
C1521721 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.18
Code List
Has the patient received erythropoietin-type agents (e.g., Epogen, Procrit or Aranesp)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed 5
Item
Did patient experience a thrombotic event (NOTE: Event must be reported through AdEERS and on the E4A03 Adverse Event Form)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C25599 (NCI Thesaurus Property)
C1441672 (UMLS 2011AA Property)
CL.10
Code List
Did patient experience a thrombotic event (NOTE: Event must be reported through AdEERS and on the E4A03 Adverse Event Form)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ThrombosisAdverseEventObservedDate
Item
Date of thrombotic event (If yes, - List Date of thrombotic events this report period. Mark an ¿X¿ in the box on the right if not applicable.)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C25599 (NCI Thesaurus Property)
C1441672 (UMLS 2011AA Property)
DataUnknownText
Item
Mark an 'X' if N/A
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C17998 (NCI Thesaurus Property)
C0439673 (UMLS 2011AA Property)
Item
Was the patient on thrombotic prophylaxis (NOTE: If more then one thrombotic event this report period, answer question below with regards to the first thrombotic event this report period.)
text
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.11
Code List
Was the patient on thrombotic prophylaxis (NOTE: If more then one thrombotic event this report period, answer question below with regards to the first thrombotic event this report period.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Aspirin (81 mg) (Were any of the following given prior to the first thrombotic event this report period? answer no 1 or yes 2 for each of the following)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C49341 (NCI Thesaurus Property)
C1708745 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.12
Code List
Aspirin (81 mg) (Were any of the following given prior to the first thrombotic event this report period? answer no 1 or yes 2 for each of the following)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Aspirin (325 mg)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C49342 (NCI Thesaurus Property)
C1709056 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.13
Code List
Aspirin (325 mg)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Aspirin (other dose)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.14
Code List
Aspirin (other dose)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedDose
Item
If other dose of Aspirin given, specify dose
double
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C287 (NCI Thesaurus Property)
C0004057 (UMLS 2011AA Property)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
Item
Coumadin
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C945 (NCI Thesaurus Property)
C0043031 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.15
Code List
Coumadin
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Coumadin given, specify dose
double
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C945 (NCI Thesaurus Property)
C0043031 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
CL.16
Code List
If Coumadin given, specify dose
CL Item
No (No)
CL Item
Yes (Yes)
Item
Low molecular weight heparin (enoxaparin; Lovenox)
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C2578 (NCI Thesaurus Property)
C0019139 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.17
Code List
Low molecular weight heparin (enoxaparin; Lovenox)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
DeepVeinThrombosisPreventionTherapyReceivedSpecify
Item
Other, specify
text
C49343 (NCI Thesaurus ObjectClass)
C0149871 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C15405 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Has the patient received erythropoietin-type agents (e.g., Epogen, Procrit or Aranesp)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C20429 (NCI Thesaurus ObjectClass)
C0014822 (UMLS 2011AA ObjectClass)
C37902 (NCI Thesaurus ObjectClass)
C1521721 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.18
Code List
Has the patient received erythropoietin-type agents (e.g., Epogen, Procrit or Aranesp)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Comments
InvestigatorSignatureText
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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