ID

24294

Description

AMC-075 Pregnancy Outcome Form (PRO) Lymphoma HIV Vorinostat Rituximab NCT01193842 On-Study - AMC-075 Pregnancy Outcome Form (PRO) - 3228008v1.0 Vorinostat and Combination Chemotherapy With Rituximab in Treating Patients With Previously Untreated HIV-Related Diffuse Large B-Cell Non-Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0F9B852-8D17-8306-E040-BB89AD434EB4

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0F9B852-8D17-8306-E040-BB89AD434EB4

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/29/17 7/29/17 - Martin Dugas
Uploaded on

July 29, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lymphoma HIV Vorinostat Rituximab NCT01193842 AMC-075

English

For date fields, if the month and year are known, but the exact date is not, please enter "15" for the day.

1 forms  
Header Module
Description

Header Module

Alias
UMLS CUI-1
C1320722
Sequence number
Description

SequentialFormSubmissionCount

Data type

integer

Alias
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus ObjectClass-2
C49153
NCI Thesaurus Property
C25694
UMLS CUI [1]
C2348184
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1]
C0947611
Pregnancy Status
Description

Pregnancy Status

Pregnancy Status
Description

PersonPregnancyPregnancyStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Pregnancy Outcome - Live Birth Only
Description

Pregnancy Outcome - Live Birth Only

Alias
UMLS CUI-1
C0032972
UMLS CUI-2
C0481667
Delivery Date
Description

Pregnancy Delivery Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property
C61560
UMLS CUI [1]
C2053594
Gestational age, Weeks
Description

PregnancyWeekNumberCount

Data type

integer

Measurement units
  • weeks
Alias
NCI Thesaurus Property
C25337
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property-2
C29844
UMLS CUI [1]
C0017504
weeks
Gestational age, Days
Description

PregnancyDayCount

Data type

integer

Measurement units
  • Days
Alias
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property
C25301
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25301
NCI Thesaurus ValueDomain-2
C25463
UMLS CUI [1]
C0017504
Days
Birth weight, pounds
Description

PersonMeasuredBirthPoundWeightCount

Data type

float

Measurement units
  • pounds
Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25208
NCI Thesaurus Property-2
C48531
NCI Thesaurus Property-3
C25155
NCI Thesaurus Property-4
C44473
NCI Thesaurus ValueDomain
C25463
UMLS CUI [1]
C0005612
pounds
Birth weight, ounces
Description

PersonMeasuredBirthOunceWeightCount

Data type

float

Measurement units
  • ounces
Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25208
NCI Thesaurus Property-2
C48519
NCI Thesaurus Property-3
C25155
NCI Thesaurus Property-4
C44473
NCI Thesaurus ValueDomain
C25463
UMLS CUI [1]
C0005612
ounces
Birth length, Inches
Description

PersonRecumbentLengthValue

Data type

float

Measurement units
  • Inches
Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25334
NCI Thesaurus Property-2
C77532
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25334
UMLS CUI [1]
C0419415
Inches
One minute Apgar Score
Description

ApgarScoreOneMinuteNumberValue

Data type

integer

Alias
NCI Thesaurus ObjectClass
C73437
NCI Thesaurus Property
C48154
NCI Thesaurus Property-2
C66832
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ValueDomain-2
C66833
NCI Thesaurus ValueDomain-3
C73791
UMLS CUI [1]
C0426279
Five minute Apgar Score
Description

ApgarScoreFiveMinuteNumberValue

Data type

integer

Alias
NCI Thesaurus ObjectClass
C73437
NCI Thesaurus Property
C48154
NCI Thesaurus Property-2
C66836
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ValueDomain-2
C66833
NCI Thesaurus ValueDomain-3
C73791
UMLS CUI [1]
C0426291
Unknown
Description

Data Unknown

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C17998
UMLS CUI [1]
C0439673
Were there any clinical problems with the infant
Description

PhysicalExaminationNewbornExaminationPerformedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C20989
NCI Thesaurus Property
C38000
NCI Thesaurus Property-2
C84749
UMLS CUI [1]
C1254481
Specify
Description

PregnancyBirthOutcomeText (If yes)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus Property
C20200
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property-2
C25155
UMLS CUI [1,1]
C1521902
Were there any problems with delivery
Description

PregnancyLaborandDeliveryComplicationPresentInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C25626
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property-2
C87091
UMLS CUI [1]
C0269815
Specify
Description

NewbornAbnormalityContributingFactorText (If yes)

Data type

text

Alias
NCI Thesaurus ObjectClass
C16731
NCI Thesaurus Property
C9440
NCI Thesaurus Property-2
C61412
NCI Thesaurus Property-3
C25506
NCI Thesaurus ValueDomain
C25704
UMLS CUI [1,1]
C1521902
Is there a congenital anomaly
Description

PersonCongenitalAbnormalityPregnancyInd-3 (If Yes, report as an SAE.)

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C25742
NCI Thesaurus Property-2
C2849
UMLS CUI [1]
C0000768
Specify
Description

PatientCongenitalAbnormalitySpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C2849
UMLS CUI [1]
C0000768
Was neonatal testing performed
Description

DiagnosticProcedureFetalExaminationPerformedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C38000
NCI Thesaurus ObjectClass
C18020
NCI Thesaurus Property-2
C92714
UMLS CUI [1]
C0947980
Were there any abnormal test results
Description

AbnormalFindingDiagnosticProcedureFetalExaminationPerformedInd-3 (If yes)

Data type

text

Alias
NCI Thesaurus ObjectClass
C18020
NCI Thesaurus ObjectClass-2
C82547
NCI Thesaurus Property
C38000
NCI Thesaurus Property-2
C92714
NCI Thesaurus ValueDomain
C38148
UMLS CUI [1]
C0459424
Specify
Description

TherapeuticProcedurePregnancyAssociatedPerformedAbnormalSpecify (If yes including dates)

Data type

text

Alias
NCI Thesaurus ObjectClass
C49236
NCI Thesaurus Property
C38000
NCI Thesaurus Property-2
C25742
NCI Thesaurus Property-3
C25281
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ValueDomain-2
C25401
UMLS CUI [1,1]
C1521902
Pregnancy Outcome - Spontaneous Abortion, Still Birth, Or Elective Abortion Only
Description

Pregnancy Outcome - Spontaneous Abortion, Still Birth, Or Elective Abortion Only

Alias
UMLS CUI-1
C0032972
Date
Description

PersonPregnancyOutcomeDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C25742
UMLS CUI [1,1]
C0011008
Gestational age, Weeks
Description

PregnancyWeekNumberCount

Data type

integer

Measurement units
  • weeks
Alias
NCI Thesaurus Property
C25337
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property-2
C29844
UMLS CUI [1]
C0017504
weeks
Gestational age, Days
Description

PregnancyDayCount

Data type

integer

Measurement units
  • Days
Alias
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property
C25301
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25301
NCI Thesaurus ValueDomain-2
C25463
UMLS CUI [1]
C0017504
Days
If spontaneous abortion or still birth, specify circumstances
Description

PregnancyPersonSpontaneousAbortionStillbirthPresentSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25742
NCI Thesaurus Property
C25626
NCI Thesaurus Property-2
C34336
NCI Thesaurus Property-3
C49151
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1]
C0814606
Was any congenital anomaly evident in the fetus
Description

FetusPersonCongenitalAbnormalityAbortionInd-3 (If Yes, report as an SAE.)

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C13235
NCI Thesaurus Property
C2849
NCI Thesaurus Property-2
C35221
NCI Thesaurus ValueDomain
C38148
UMLS CUI [1]
C0000768
Specify
Description

PatientCongenitalAbnormalitySpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C2849
UMLS CUI [1]
C0000768
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Similar models

For date fields, if the month and year are known, but the exact date is not, please enter "15" for the day.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Sequence number
Item
Sequence number
integer
C19464 (NCI Thesaurus ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C49153 (NCI Thesaurus ObjectClass-2)
C25694 (NCI Thesaurus Property)
C2348184 (UMLS CUI [1])
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1])
Item Group
Pregnancy Status
Item
Pregnancy Status
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.1
Code List
Pregnancy Status
CL Item
Pregnancy Ongoing (Pregnancy ongoing)
CL Item
Live Birth (Live birth)
CL Item
Spontaneous Abortion/miscarriage (Spontaneous abortion/miscarriage)
CL Item
Still Birth (Still birth)
CL Item
Elective Abortion (Elective abortion)
CL Item
Unknown (Unknown)
Item Group
Pregnancy Outcome - Live Birth Only
C0032972 (UMLS CUI-1)
C0481667 (UMLS CUI-2)
Pregnancy Delivery Date
Item
Delivery Date
date
C25164 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus ObjectClass)
C61560 (NCI Thesaurus Property)
C2053594 (UMLS CUI [1])
Gestational age
Item
Gestational age, Weeks
integer
C25337 (NCI Thesaurus Property)
C25463 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus ObjectClass)
C29844 (NCI Thesaurus Property-2)
C0017504 (UMLS CUI [1])
Gestational age
Item
Gestational age, Days
integer
C25742 (NCI Thesaurus ObjectClass)
C25301 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25301 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0017504 (UMLS CUI [1])
Birth weight
Item
Birth weight, pounds
float
C25190 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
C48531 (NCI Thesaurus Property-2)
C25155 (NCI Thesaurus Property-3)
C44473 (NCI Thesaurus Property-4)
C25463 (NCI Thesaurus ValueDomain)
C0005612 (UMLS CUI [1])
Birth weight
Item
Birth weight, ounces
float
C25190 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
C48519 (NCI Thesaurus Property-2)
C25155 (NCI Thesaurus Property-3)
C44473 (NCI Thesaurus Property-4)
C25463 (NCI Thesaurus ValueDomain)
C0005612 (UMLS CUI [1])
Birth length
Item
Birth length, Inches
float
C25190 (NCI Thesaurus ObjectClass)
C25334 (NCI Thesaurus Property)
C77532 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25334 (NCI Thesaurus ValueDomain-2)
C0419415 (UMLS CUI [1])
One minute Apgar Score
Item
One minute Apgar Score
integer
C73437 (NCI Thesaurus ObjectClass)
C48154 (NCI Thesaurus Property)
C66832 (NCI Thesaurus Property-2)
C25337 (NCI Thesaurus ValueDomain)
C66833 (NCI Thesaurus ValueDomain-2)
C73791 (NCI Thesaurus ValueDomain-3)
C0426279 (UMLS CUI [1])
Five minute Apgar Score
Item
Five minute Apgar Score
integer
C73437 (NCI Thesaurus ObjectClass)
C48154 (NCI Thesaurus Property)
C66836 (NCI Thesaurus Property-2)
C25337 (NCI Thesaurus ValueDomain)
C66833 (NCI Thesaurus ValueDomain-2)
C73791 (NCI Thesaurus ValueDomain-3)
C0426291 (UMLS CUI [1])
Data Unknown
Item
Unknown
text
C25704 (NCI Thesaurus ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C17998 (NCI Thesaurus Property)
C0439673 (UMLS CUI [1])
Item
Were there any clinical problems with the infant
text
C38148 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C38000 (NCI Thesaurus Property)
C84749 (NCI Thesaurus Property-2)
C1254481 (UMLS CUI [1])
CL.2
Code List
Were there any clinical problems with the infant
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Specify
Item
Specify
text
C25704 (NCI Thesaurus ValueDomain)
C20200 (NCI Thesaurus Property)
C25742 (NCI Thesaurus ObjectClass)
C25155 (NCI Thesaurus Property-2)
C1521902 (UMLS CUI [1,1])
Item
Were there any problems with delivery
text
C38148 (NCI Thesaurus ValueDomain)
C25626 (NCI Thesaurus Property)
C25742 (NCI Thesaurus ObjectClass)
C87091 (NCI Thesaurus Property-2)
C0269815 (UMLS CUI [1])
CL.3
Code List
Were there any problems with delivery
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Specify
Item
Specify
text
C16731 (NCI Thesaurus ObjectClass)
C9440 (NCI Thesaurus Property)
C61412 (NCI Thesaurus Property-2)
C25506 (NCI Thesaurus Property-3)
C25704 (NCI Thesaurus ValueDomain)
C1521902 (UMLS CUI [1,1])
Item
Is there a congenital anomaly
text
C25190 (NCI Thesaurus ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus Property)
C2849 (NCI Thesaurus Property-2)
C0000768 (UMLS CUI [1])
CL.4
Code List
Is there a congenital anomaly
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Congenital anomaly, specify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C2849 (NCI Thesaurus Property)
C0000768 (UMLS CUI [1])
Item
Was neonatal testing performed
text
C38148 (NCI Thesaurus ValueDomain)
C38000 (NCI Thesaurus Property)
C18020 (NCI Thesaurus ObjectClass)
C92714 (NCI Thesaurus Property-2)
C0947980 (UMLS CUI [1])
CL.5
Code List
Was neonatal testing performed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Were there any abnormal test results
text
C18020 (NCI Thesaurus ObjectClass)
C82547 (NCI Thesaurus ObjectClass-2)
C38000 (NCI Thesaurus Property)
C92714 (NCI Thesaurus Property-2)
C38148 (NCI Thesaurus ValueDomain)
C0459424 (UMLS CUI [1])
CL.6
Code List
Were there any abnormal test results
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Specify
Item
Specify
text
C49236 (NCI Thesaurus ObjectClass)
C38000 (NCI Thesaurus Property)
C25742 (NCI Thesaurus Property-2)
C25281 (NCI Thesaurus Property-3)
C25685 (NCI Thesaurus ValueDomain)
C25401 (NCI Thesaurus ValueDomain-2)
C1521902 (UMLS CUI [1,1])
Item Group
Pregnancy Outcome - Spontaneous Abortion, Still Birth, Or Elective Abortion Only
C0032972 (UMLS CUI-1)
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C25742 (NCI Thesaurus Property-2)
C0011008 (UMLS CUI [1,1])
Gestational age
Item
Gestational age, Weeks
integer
C25337 (NCI Thesaurus Property)
C25463 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus ObjectClass)
C29844 (NCI Thesaurus Property-2)
C0017504 (UMLS CUI [1])
Gestational age
Item
Gestational age, Days
integer
C25742 (NCI Thesaurus ObjectClass)
C25301 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25301 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0017504 (UMLS CUI [1])
circumstances
Item
If spontaneous abortion or still birth, specify circumstances
text
C25190 (NCI Thesaurus ObjectClass)
C25742 (NCI Thesaurus ObjectClass-2)
C25626 (NCI Thesaurus Property)
C34336 (NCI Thesaurus Property-2)
C49151 (NCI Thesaurus Property-3)
C25685 (NCI Thesaurus ValueDomain)
C0814606 (UMLS CUI [1])
Item
Was any congenital anomaly evident in the fetus
text
C25190 (NCI Thesaurus ObjectClass)
C13235 (NCI Thesaurus ObjectClass-2)
C2849 (NCI Thesaurus Property)
C35221 (NCI Thesaurus Property-2)
C38148 (NCI Thesaurus ValueDomain)
C0000768 (UMLS CUI [1])
CL.7
Code List
Was any congenital anomaly evident in the fetus
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Congenital anomaly, specify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C2849 (NCI Thesaurus Property)
C0000768 (UMLS CUI [1])
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