ID

23820

Beschrijving

E2805 Concomitant Medication Form Sunitinib or Sorafenib in Treating Patients With Kidney Cancer That Was Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0B593E1B-ACB3-37BB-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0B593E1B-ACB3-37BB-E044-0003BA3F9857

Trefwoorden

Versies (8)
  1. 19-09-12 19-09-12 -
  2. 26-11-14 26-11-14 - Martin Dugas
  3. 26-11-14 26-11-14 - Martin Dugas
  4. 26-11-14 26-11-14 - Martin Dugas
  5. 08-01-15 08-01-15 - Martin Dugas
  6. 09-01-15 09-01-15 - Martin Dugas
  7. 09-01-15 09-01-15 - Martin Dugas
  8. 14-07-17 14-07-17 - Martin Dugas
Geüploaded op

14 juli 2017

DOI

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Licentie

Creative Commons BY-NC 3.0
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Kidney Cancer NCT00326898 Treatment - E2805 Concomitant Medication Form - 2444090v1.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: E2805 Concomitant Medication Form
    1. No Instruction available.
Administrative documentation
Beschrijving

Administrative documentation

Alias
UMLS CUI-1
C1320722
ECOG Protocol Number
Beschrijving

Protocol Number ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Protocol Number
Beschrijving

Protocol Number ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Patient ID
Beschrijving

Patient ID ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Patient ID
Beschrijving

Patient ID ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
DCI Name
Beschrijving

Generic drug form

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C3242750
NCI Thesaurus Property
C19464
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus ObjectClass-2
C25452
Registration Step
Beschrijving

Registration Number

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1514821
NCI Thesaurus ObjectClass
C25646
UMLS CUI-2
C0237753
NCI Thesaurus Property
C16154
NCI Thesaurus ValueDomain-2
C16154
Patient Initials
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
ECOG Protocol Number
Beschrijving

Protocol Number ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Protocol Number
Beschrijving

Protocol Number ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
Participating Group Protocol Number
Beschrijving

Study Number Participating Group

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Institution/Affiliate
Beschrijving

Institution Name

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
ECOG Patient ID
Beschrijving

Patient ID ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Patient ID
Beschrijving

Patient ID ECOG

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
Participating Group Patient ID
Beschrijving

Trial subject ID Participating Group

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Concomitant medication
Beschrijving

Concomitant medication

Alias
UMLS CUI-1
C2347852
UMLS CUI-2
Agent Name (Generic Name)
Beschrijving

Agent

Datatype

text

Alias
NCI Thesaurus Property
C25364
UMLS CUI-1
C1521826
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
Reporting period Start Date
Beschrijving

Reporting Period Start Date

Datatype

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25616
UMLS CUI-1
C2361257
NCI Thesaurus Property-2
C25651
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
Reporting period End Date
Beschrijving

Reporting Period End Date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2361259
NCI Thesaurus Property
C25616
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property-2
C25651
Dose
Beschrijving

Medication Dose

Datatype

float

Alias
NCI Thesaurus ValueDomain
C25488
UMLS CUI-1
C3174092
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain-2
C1708
NCI Thesaurus Property
C25382
Units (*)
Beschrijving

Agent Unit

Datatype

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS CUI-1
C0450442
NCI Thesaurus Property
C25730
UMLS CUI-2
C1519795
NCI Thesaurus Property-2
C25409
NCI Thesaurus ValueDomain
C25709
other, specify
Beschrijving

ECOGMedicationUOMSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25491
UMLS 2011AA ObjectClass
C1512162
NCI Thesaurus ObjectClass-2
C459
UMLS 2011AA ObjectClass-2
C0013227
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Frequency (**)
Beschrijving

Medication frequency

Datatype

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS CUI-1
C3476109
NCI Thesaurus ValueDomain
C25515
NCI Thesaurus Property
C25382
other, specify
Beschrijving

Medication frequency

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C3476109
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ObjectClass-2
C25409
NCI Thesaurus Property
C25275
Route (***)
Beschrijving

Drug Administration Route

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0013153
NCI Thesaurus ObjectClass
C459
NCI Thesaurus ObjectClass-2
C25409
NCI Thesaurus Property
C25169
other, specify
Beschrijving

MedicationAdministrationRouteSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass-2
C25409
UMLS 2011AA ObjectClass-2
C1533734
NCI Thesaurus Property
C25169
UMLS 2011AA Property
C0449444
Agent Start Date (Leave blank if continuing from a prior report period)
Beschrijving

Concomitant Medication Start Date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2826734
NCI Thesaurus ValueDomain-2
C25431
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25275
Is this medication continuing?
Beschrijving

Medication continued

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0013227
NCI Thesaurus ObjectClass
C459
UMLS CUI-2
C0549178
NCI Thesaurus Property
C25409
NCI Metathesaurus Property
C0750536
Agent End Date (Leave blank if continuing)
Beschrijving

Concomitant Medication End Date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2826744
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25275
On Treatment Report Period (since start of treatment If treatment was delayed, choose the intended time period without delays.)
Beschrijving

Cycle number

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C2045829
NCI Thesaurus Property
C25214
NCI Thesaurus Property-2
C25616
NCI Thesaurus ObjectClass
C15368
Were concomitant medications used during this reporting period? (reportable)
Beschrijving

Concomitant Medication used

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C2347852
NCI Thesaurus ObjectClass
C1708
UMLS CUI-2
C1521801
NCI Thesaurus ObjectClass-2
C25730
NCI Thesaurus Property
C25382
Please mark an 'X' if data have been amended.
Beschrijving

Data amended

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Date data amended
Beschrijving

Data amended date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
UMLS CUI-2
C0011008
NCI Thesaurus Property
C25416
NCI Thesaurus ValueDomain-2
C25367
Comments
Beschrijving

Comments

Comments
Beschrijving

Research Comments

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Investigator Signature
Beschrijving

Investigator Signature

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
Investigator Signature Date
Beschrijving

Investigator Signature Date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
UMLS CUI-2
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C17089
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1 Formulieren
  1. StudyEvent: E2805 Concomitant Medication Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative documentation
C1320722 (UMLS CUI-1)
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Generic drug form
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
Registration Number
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Study Number Participating Group
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Concomitant medication
C2347852 (UMLS CUI-1)
(UMLS CUI-2)
Agent
Item
Agent Name (Generic Name)
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
Reporting Period Start Date
Item
Reporting period Start Date
date
C15368 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C2361257 (UMLS CUI-1)
C25651 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
Reporting Period End Date
Item
Reporting period End Date
date
C25164 (NCI Thesaurus ValueDomain)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
Medication Dose
Item
Dose
float
C25488 (NCI Thesaurus ValueDomain)
C3174092 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain-2)
C25382 (NCI Thesaurus Property)
Item
Units (*)
text
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS CUI-1)
C25730 (NCI Thesaurus Property)
C1519795 (UMLS CUI-2)
C25409 (NCI Thesaurus Property-2)
C25709 (NCI Thesaurus ValueDomain)
CL.3
Code List
Units (*)
CL Item
Capsules (capsules)
CL Item
Gram (gram)
C48155 (NCI Thesaurus)
C0439208 (UMLS 2011AA)
CL Item
Drops (drops)
C69442 (NCI Thesaurus)
C2347093 (UMLS 2011AA)
CL Item
Inch (inch)
C48500 (NCI Thesaurus)
C0439204 (UMLS 2011AA)
CL Item
Kilograms (kilogram)
C28252 (NCI Thesaurus)
C0439209 (UMLS 2011AA)
CL Item
Liter (liter)
CL Item
Microgram (microgram)
CL Item
Milliequivalent (milliequivalent)
CL Item
Milligram (milligram)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
CL Item
Milliliter (milliliter)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Ounce (ounce)
C48519 (NCI Thesaurus)
C0439218 (UMLS 2011AA)
CL Item
Tablets (tablets)
CL Item
Tablespoon (tablespoon)
CL Item
Teaspoon (teaspoon)
CL Item
Unit (unit)
C44278 (NCI Thesaurus)
C0439148 (UMLS 2011AA)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ECOGMedicationUOMSpecify
Item
other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25491 (NCI Thesaurus ObjectClass)
C1512162 (UMLS 2011AA ObjectClass)
C459 (NCI Thesaurus ObjectClass-2)
C0013227 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Frequency (**)
text
C1708 (NCI Thesaurus ObjectClass)
C3476109 (UMLS CUI-1)
C25515 (NCI Thesaurus ValueDomain)
C25382 (NCI Thesaurus Property)
CL.4
Code List
Frequency (**)
CL Item
Immediately (stat) (immediately)
CL Item
As Needed (p.r.n) (as needed)
CL Item
Every Day (q.d.) (every day)
CL Item
Every Other Day (q.o.d.) (every other day)
CL Item
Twice A Day (b.i.d) (twice a day)
CL Item
Three Times A Day (t.i.d) (three times a day)
CL Item
Four Times A Day (q.i.d) (four times a day)
CL Item
Twice A Week (b.i.w) (twice a week)
CL Item
Three Times A Week (t.i.w) (three times a week)
CL Item
Before Meals (a.c.) (before meals)
CL Item
After Meals (p.c.) (after meals)
CL Item
At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep)
CL Item
Every 4 Hours (q4hr) (every 4 hours)
CL Item
Every 6 Hours (q6hr) (every 6 hours)
CL Item
Every 8 Hours (q8hr) (every 8 hours)
CL Item
Every 12 Hours (q12hr) (every 12 hours)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Medication frequency
Item
other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C3476109 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C25409 (NCI Thesaurus ObjectClass-2)
C25275 (NCI Thesaurus Property)
Item
Route (***)
text
C25284 (NCI Thesaurus ValueDomain)
C0013153 (UMLS CUI-1)
C459 (NCI Thesaurus ObjectClass)
C25409 (NCI Thesaurus ObjectClass-2)
C25169 (NCI Thesaurus Property)
CL.5
Code List
Route (***)
CL Item
Oral (PO)
C25311 (NCI Thesaurus)
C0442027 (UMLS 2011AA)
C25311 (NCI Thesaurus-3)
C0442027 (UMLS 2011AA-4)
CL Item
Subcutaneous (SC)
C13353 (NCI Thesaurus)
C0443315 (UMLS 2011AA)
C13353 (NCI Thesaurus-3)
C0443315 (UMLS 2011AA-4)
CL Item
Intramuscular (IM)
C27974 (NCI Thesaurus)
C0442117 (UMLS 2011AA)
C27974 (NCI Thesaurus-3)
C0442117 (UMLS 2011AA-4)
CL Item
Intravenous (IV)
X-MO-6794 (MGED)
X-MO-6794 (MGED-2)
CL Item
Rectal (rectal)
C25224 (NCI Thesaurus)
C0205052 (UMLS 2011AA)
CL Item
Topical (topical)
C13344 (NCI Thesaurus)
C0332237 (UMLS 2011AA)
C13344 (NCI Thesaurus-3)
C0332237 (UMLS 2011AA-4)
CL Item
Nasal (nasal)
C27958 (NCI Thesaurus)
C0028429 (UMLS 2011AA)
CL Item
Inhaled (inhaled)
CL Item
Transdermal (transdermal)
C28017 (NCI Thesaurus)
C0694643 (UMLS 2011AA)
CL Item
Sublingual (sublingual)
C89785 (NCI Thesaurus)
CL Item
Intradermal (intradermal)
C28213 (NCI Thesaurus)
C0150647 (UMLS 2011AA)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
MedicationAdministrationRouteSpecify
Item
other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus ObjectClass-2)
C1533734 (UMLS 2011AA ObjectClass-2)
C25169 (NCI Thesaurus Property)
C0449444 (UMLS 2011AA Property)
Concomitant Medication Start Date
Item
Agent Start Date (Leave blank if continuing from a prior report period)
date
C25164 (NCI Thesaurus ValueDomain)
C2826734 (UMLS CUI-1)
C25431 (NCI Thesaurus ValueDomain-2)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
Medication continued
Item
Is this medication continuing?
boolean
C38147 (NCI Thesaurus ValueDomain)
C0013227 (UMLS CUI-1)
C459 (NCI Thesaurus ObjectClass)
C0549178 (UMLS CUI-2)
C25409 (NCI Thesaurus Property)
C0750536 (NCI Metathesaurus Property)
Concomitant Medication End Date
Item
Agent End Date (Leave blank if continuing)
date
C25164 (NCI Thesaurus ValueDomain)
C2826744 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
Item
On Treatment Report Period (since start of treatment If treatment was delayed, choose the intended time period without delays.)
text
C25284 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
CL.1
Code List
On Treatment Report Period (since start of treatment If treatment was delayed, choose the intended time period without delays.)
CL Item
Baseline (Baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
C25213 (NCI Thesaurus-3)
C1442488 (UMLS 2011AA-4)
CL Item
Cycle 1 (Cycle 1)
CL Item
Cycle 2 (Cycle 2)
CL Item
Cycle 3 (Cycle 3)
CL Item
Cycle 4 (Cycle 4)
CL Item
Cycle 5 (Cycle 5)
CL Item
Cycle 6 (Cycle 6)
CL Item
Cycle 7 (Cycle 7)
CL Item
Cycle 8 (Cycle 8)
CL Item
Cycle 9 (Cycle 9)
Concomitant Medication used
Item
Were concomitant medications used during this reporting period? (reportable)
boolean
C38147 (NCI Thesaurus ValueDomain)
C2347852 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1521801 (UMLS CUI-2)
C25730 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
Data amended
Item
Please mark an 'X' if data have been amended.
text
C25704 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Data amended date
Item
Date data amended
date
C25164 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Investigator Signature
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
Investigator Signature Date
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
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