ID

2472

Beskrivning

ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form Surgery With or Without Internal Radiation Therapy Compared With Stereotactic Body Radiation Therapy in Treating Patients With High-Risk Stage I Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=98F2A8AC-D8D1-9DE5-E040-BB89AD434043

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=98F2A8AC-D8D1-9DE5-E040-BB89AD434043

Nyckelord

Versioner (2)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

19 september 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT01336894 On-Study - ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form - 3179637v1.0

Engelsk

ALL ITEMS MUST BE COMPLETED

1 Formulär  
  1. StudyEvent: ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form
    1. ALL ITEMS MUST BE COMPLETED
Header Module
Beskrivning

Header Module

Protocol Number
Beskrivning

ProtocolACOSOGIdentifierNumber

Datatyp

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
C19712
UMLS 2011AA Property
C1515944
Patient ID
Beskrivning

PatientCoordinatingIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials (L F M)
Beskrivning

PatientInitialsName

Datatyp

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
Institution Number
Beskrivning

InstitutionIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution
Beskrivning

InstitutionName

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Are data amended (check one if data amended, please circle in red when using paper forms)
Beskrivning

DataAmendedInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Visit
Beskrivning

Visit

Visit (after registration and before SBRT or surgery)
Beskrivning

AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C19712
UMLS 2011AA ObjectClass
C1515944
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Comorbid Conditions
Beskrivning

Comorbid Conditions

Comorbidity (check one)
Beskrivning

ConcomitantDiseasePersonalMedicalHistoryType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C25730
UMLS 2011AA ObjectClass
C0521115
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Present (check one)
Beskrivning

ChronicDiseasePresentInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C14141
UMLS 2011AA ObjectClass
C0205191
Tillbaka till toppen

Similar models

ALL ITEMS MUST BE COMPLETED

1 Formulär
  1. StudyEvent: ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form
    1. ALL ITEMS MUST BE COMPLETED
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Header Module
ProtocolACOSOGIdentifierNumber
Item
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)
C19712 (NCI Thesaurus Property)
C1515944 (UMLS 2011AA Property)
PatientCoordinatingIdentifierNumber
Item
Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials (L F M)
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)
InstitutionIdentifierNumber
Item
Institution Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InstitutionName
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Are data amended (check one if data amended, please circle in red when using paper forms)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended (check one if data amended, please circle in red when using paper forms)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Visit
Item
Visit (after registration and before SBRT or surgery)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19712 (NCI Thesaurus ObjectClass)
C1515944 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
CL.2
Code List
Visit (after registration and before SBRT or surgery)
CL Item
Registration (Registration)
C25646 (NCI Thesaurus)
C1514821 (UMLS 2011AA)
Item Group
Comorbid Conditions
Item
Comorbidity (check one)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
CL.3
Code List
Comorbidity (check one)
CL Item
Myocardial Infarction (Myocardial infarction)
C27996 (NCI Thesaurus)
C0027051 (UMLS 2011AA)
CL Item
Congestive Heart Failure (Congestive heart failure)
C3080 (NCI Thesaurus)
C0018802 (UMLS 2011AA)
CL Item
Peripheral Vascular Disease (Peripheral vascular disease)
CL Item
Cerebrovascular Disease (Cerebrovascular disease)
CL Item
Dementia (Dementia)
CL Item
Chronic Pulmonary Disease (Chronic pulmonary disease)
CL Item
Connective Tissue Disease (Connective tissue disease)
CL Item
Ulcer (Ulcer disease)
C3426 (NCI Thesaurus)
C0041582 (UMLS 2011AA)
CL Item
Mild Liver Disease (Mild liver disease)
CL Item
Diabetes (Diabetes)
CL Item
Diabetes Complication (Diabetes with end organ damage)
C84415 (NCI Thesaurus)
C0342257 (UMLS 2011AA)
CL Item
Hemiplegia (Hemiplegia)
CL Item
Renal Disorder (Moderate or severe renal disease)
C3149 (NCI Thesaurus)
C0022658 (UMLS 2011AA)
CL Item
Second Solid Tumor (Second Solid tumor)
CL Item
Leukemia (Leukemia)
C3161 (NCI Thesaurus)
C0023418 (UMLS 2011AA)
CL Item
Lymphoma, Multiple Myeloma, Nhl, Hodgkin's, Waldenstrom (Lymphoma, Multiple Myeloma, NHL, Hodgkin's, Waldenstrom)
CL Item
Liver And Biliary Tract Disorder (Moderate or severe liver disease)
C3959 (NCI Thesaurus)
C0267792 (UMLS 2011AA)
CL Item
Second Metastatic Solid Tumor (Second Metastatic solid tumor)
CL Item
Aids (AIDS)
Item
Present (check one)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass)
C0205191 (UMLS 2011AA ObjectClass)
CL.4
Code List
Present (check one)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Tillbaka till toppen 

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