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2400

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E4A03 Thrombotic Event Prior September 14, 2005 Summary Form 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=0615D022-651B-5424-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0615D022-651B-5424-E044-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/16/15 6/16/15 -
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September 19, 2012

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Creative Commons BY-NC 3.0 Legacy
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    Multiple Myeloma and Plasma Cell Neoplasm NCT00098475 Treatment - E4A03 Thrombotic Event Prior September 14, 2005 Summary Form - 2432193v1.0

    English

    ONLY if patient?s disease is still stable or in partial or complete remission and has not progressed/relapsed from protocol therapy.

    1 forms  
    Unnamed1
    Description

    Unnamed1

    ECOG Protocol Number
    Description

    ProtocolECOGIdentifierNumber

    Data type

    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
    DCI Name
    Description

    CollectedDataFormName

    Data type

    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
    Description

    RegistrationStepNumber

    Data type

    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
    ECOG Patient ID
    Description

    PatientECOGIdentifierNumber

    Data type

    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
    Reporting Period
    Description

    ReportingEvaluationPeriodType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C25214
    UMLS 2011AA ObjectClass
    C0220825
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ObjectClass
    C25651
    UMLS 2011AA ObjectClass
    C0700287
    Unnamed2
    Description

    Unnamed2

    Patient Initials
    Description

    PatientInitialsName

    Data type

    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 Protocol Number
    Description

    ProtocolECOGIdentifierNumber

    Data type

    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
    Participating Group Protocol Number
    Description

    ProtocolParticipatingIdentifierNumber

    Data type

    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
    Description

    CombinedInstitutionName

    Data type

    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
    ECOG Patient ID
    Description

    PatientECOGIdentifierNumber

    Data type

    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 Patient ID
    Description

    PatientParticipatingIdentifierNumber

    Data type

    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
    Description

    Unnamed3

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

    DataAmendedText

    Data type

    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
    Description

    DataAmendedDate

    Data type

    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
    Unnamed 4
    Description

    Unnamed 4

    Did patient recieve DVT prophylaxis (prior to September 14, 2005)
    Description

    DeepVeinThrombosisPreventionTherapyReceivedInd-2

    Data type

    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
    Description

    DeepVeinThrombosisPreventionReceivedBeginDate

    Data type

    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
    Description

    DeepVeinThrombosisPreventionReceivedMostRecentDate

    Data type

    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)
    Description

    DeepVeinThrombosisPreventionTherapyLowDoseAcetylsalicylicAcidReceivedInd-2

    Data type

    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)
    Description

    DeepVeinThrombosisPreventionTherapyModerateDoseAcetylsalicylicAcidReceivedInd-2

    Data type

    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)
    Description

    DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedInd-2

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedDose

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyWarfarinReceivedInd-2

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyWarfarinReceivedDose

    Data type

    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)
    Description

    DeepveinthrombosisPreventionTherapyLowMolecularWeightHeparinReceivedInd-2

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyReceivedSpecify

    Data type

    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) (prior to the first thrombotic event?)
    Description

    ErythropoietinSupportAdministeredInd-3

    Data type

    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
    Description

    Unnamed 5

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

    ThrombosisAdverseEventObservedInd-3

    Data type

    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.)
    Description

    ThrombosisAdverseEventObservedDate

    Data type

    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
    Description

    DataUnknownText

    Data type

    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.)
    Description

    ThrombosisPreventionTherapyReceivedInd-2

    Data type

    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)
    Description

    DeepVeinThrombosisPreventionTherapyLowDoseAcetylsalicylicAcidReceivedInd-2

    Data type

    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)
    Description

    DeepVeinThrombosisPreventionTherapyModerateDoseAcetylsalicylicAcidReceivedInd-2

    Data type

    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)
    Description

    DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedInd-2

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyOtherQuantityAcetylsalicylicAcidReceivedDose

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyWarfarinReceivedInd-2

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyWarfarinReceivedDose

    Data type

    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)
    Description

    DeepveinthrombosisPreventionTherapyLowMolecularWeightHeparinReceivedInd-2

    Data type

    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
    Description

    DeepVeinThrombosisPreventionTherapyReceivedSpecify

    Data type

    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) (prior to the first thrombotic event?)
    Description

    ErythropoietinSupportAdministeredInd-3

    Data type

    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
    Description

    Comments

    Investigator Signature
    Description

    InvestigatorSignatureText

    Data type

    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
    Description

    InvestigatorSignatureDate

    Data type

    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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    ONLY if patient?s disease is still stable or in partial or complete remission and has not progressed/relapsed from protocol therapy.

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    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)
    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)
    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)
    Item
    Reporting Period
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus ObjectClass)
    C0220825 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25651 (NCI Thesaurus ObjectClass)
    C0700287 (UMLS 2011AA ObjectClass)
    CL.1
    Code List
    Reporting Period
    CL Item
    Deep Vein Thrombosis (DVT)
    Item Group
    Unnamed2
    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)
    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)
    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)
    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)
    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
    Unnamed 4
    Item
    Did patient recieve DVT prophylaxis (prior to September 14, 2005)
    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 (prior to September 14, 2005)
    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) (prior to the first thrombotic event?)
    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) (prior to the first thrombotic event?)
    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) (prior to the first thrombotic event?)
    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) (prior to the first thrombotic event?)
    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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