Information:
Error:
ID
25011
Description
AMC-064 Off-Study Summary Form (F50) Study of Blood and Tissue Samples From Patients With Aggressive Non-Hodgkin B-Cell Lymphoma or Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7C993962-288D-EDFE-E040-BB89AD43562B
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Keywords
Versions (2)
- 9/19/12 9/19/12 -
- 8/24/17 8/24/17 -
Uploaded on
August 24, 2017
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License
Creative Commons BY-NC 3.0 Legacy
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Lymphoma NCT00981097 Off Treatment - AMC-064 Off-Study Summary Form (F50) - 2983033v1.0
Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)
- StudyEvent: AMC-064 Off-Study Summary Form (F50)
Similar models
Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)
- StudyEvent: AMC-064 Off-Study Summary Form (F50)
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Off Study Summary - Rf50
C1518546 (UMLS CUI-1)
C1706244 (UMLS CUI-2)
C1706244 (UMLS CUI-2)
Off Study Date
Item
Off Study Date
date
C25164 (NCI Thesaurus ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2985813 (UMLS CUI [1,1])
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2985813 (UMLS CUI [1,1])
Item
Off Study Reason
integer
C25638 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
CL Item
Protocol-defined Follow-up Completed (1)
CL Item
Lost To Follow-up (2)
CL Item
Patient Refused Follow-up (3)
CL Item
Death (4)
CL Item
Adverse Event/side Effects/complications (5)
CL Item
Other (6)
Other, specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0947611 (UMLS CUI [1,3])
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0947611 (UMLS CUI [1,3])