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ID

23816

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

July 14, 2017

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License

Creative Commons BY-NC 3.0
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    Eligibility Checklist

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Eligibility Checklist
      1. No Instruction available.
    Eligibility Checklist
    Description

    Eligibility Checklist

    Alias
    UMLS CUI-1
    C0013893
    Visit Date
    Description

    Enter the date the form was completed i.e. the date information was gathered.

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ObjectClass
    C40988
    NCI Thesaurus Property
    C25250
    UMLS CUI [1]
    C1115437
    Checklist Number
    Description

    Note: This field cannot be modified by the user.

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25337
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C16112
    NCI Thesaurus ValueDomain-2
    C49073
    UMLS CUI [1,1]
    C1707357
    UMLS CUI [1,2]
    C1516637
    UMLS CUI [1,3]
    C0237753
    Effective Date
    Description

    Note: This field cannot be modified by the user.

    Data type

    date

    Alias
    NCI Thesaurus Property
    C25164
    NCI Thesaurus ValueDomain
    C25164
    NCI Metathesaurus ObjectClass
    CL067459
    UMLS CUI [1]
    C0011008
    Waiver Number
    Description

    Waiver Number

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25337
    NCI Thesaurus ObjectClass
    C42580
    UMLS CUI [1,1]
    C1707901
    UMLS CUI [1,2]
    C0237753
    Criterion Response
    Description

    Select the patient's status relative to the eligibility inclusion criterion.

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus ObjectClass-2
    C25171
    NCI Metathesaurus Property
    C0750484
    NCI Thesaurus ValueDomain
    C25162
    NCI Thesaurus ValueDomain-2
    C25180
    NCI Thesaurus ValueDomain-3
    C49488
    NCI Thesaurus ValueDomain-4
    C49487
    NCI Thesaurus ValueDomain-5
    C48660
    UMLS CUI [1]
    C1302261
    Sequence
    Description

    Question Display Sequence

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C21153
    NCI Thesaurus Property
    C25673
    NCI Thesaurus Property-2
    C25485
    UMLS CUI [1]
    C1519249
    Eligibility Waiver Reason
    Description

    Eligibility Waiver Reason

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25638
    NCI Thesaurus ValueDomain
    C25638
    NCI Thesaurus ObjectClass
    C42580
    NCI Thesaurus ValueDomain-2
    C42580
    UMLS CUI [1,1]
    C1707901
    UMLS CUI [1,2]
    C0566251
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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
    C0013893 (UMLS CUI-1)
    Form Completion Date
    Item
    Visit Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C40988 (NCI Thesaurus ObjectClass)
    C25250 (NCI Thesaurus Property)
    C1115437 (UMLS CUI [1])
    Checklist Number
    Item
    Checklist Number
    text
    C25337 (NCI Thesaurus Property)
    C25337 (NCI Thesaurus ValueDomain)
    C16112 (NCI Thesaurus ObjectClass)
    C49073 (NCI Thesaurus ValueDomain-2)
    C1707357 (UMLS CUI [1,1])
    C1516637 (UMLS CUI [1,2])
    C0237753 (UMLS CUI [1,3])
    Effective Date
    Item
    Effective Date
    date
    C25164 (NCI Thesaurus Property)
    C25164 (NCI Thesaurus ValueDomain)
    CL067459 (NCI Metathesaurus ObjectClass)
    C0011008 (UMLS CUI [1])
    Waiver Number
    Item
    Waiver Number
    text
    C25337 (NCI Thesaurus Property)
    C42580 (NCI Thesaurus ObjectClass)
    C1707901 (UMLS CUI [1,1])
    C0237753 (UMLS CUI [1,2])
    Item
    Criterion Response
    text
    C16960 (NCI Thesaurus ObjectClass)
    C25171 (NCI Thesaurus ObjectClass-2)
    C0750484 (NCI Metathesaurus Property)
    C25162 (NCI Thesaurus ValueDomain)
    C25180 (NCI Thesaurus ValueDomain-2)
    C49488 (NCI Thesaurus ValueDomain-3)
    C49487 (NCI Thesaurus ValueDomain-4)
    C48660 (NCI Thesaurus ValueDomain-5)
    C1302261 (UMLS CUI [1])
    CL.1
    Code List
    Criterion Response
    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)
    Question Display Sequence
    Item
    Sequence
    text
    C21153 (NCI Thesaurus ObjectClass)
    C25673 (NCI Thesaurus Property)
    C25485 (NCI Thesaurus Property-2)
    C1519249 (UMLS CUI [1])
    Eligibility Waiver Reason
    Item
    Eligibility Waiver Reason
    text
    C25638 (NCI Thesaurus Property)
    C25638 (NCI Thesaurus ValueDomain)
    C42580 (NCI Thesaurus ObjectClass)
    C42580 (NCI Thesaurus ValueDomain-2)
    C1707901 (UMLS CUI [1,1])
    C0566251 (UMLS CUI [1,2])
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