ID

25011

Descripción

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

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7C993962-288D-EDFE-E040-BB89AD43562B

Palabras clave

  1. 19/9/12 19/9/12 -
  2. 24/8/17 24/8/17 -
Subido en

24 de agosto de 2017

DOI

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Licencia

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.)

Ccrr Module For Off Study Summary - Rf50
Descripción

Ccrr Module For Off Study Summary - Rf50

Alias
UMLS CUI-1
C1518546
UMLS CUI-2
C1706244
Off Study Date
Descripción

Off-TreatmentStudyFollow-UpEndDate (mm/dd/yyyy)

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
NCI Thesaurus Property
C25275
UMLS CUI [1,1]
C2985813
Off Study Reason
Descripción

Off-TreatmentStudyFollow-UpReason (select the primary reason)

Tipo de datos

integer

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C1518546
UMLS CUI [1,3]
C0392360
Other, specify
Descripción

Off-Treatment Study Follow-Up Specify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C1518546
UMLS CUI [1,3]
C0392360
Comments
Descripción

Research Comments

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C1518546
UMLS CUI [1,3]
C0947611

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.)

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Ccrr Module For Off Study Summary - Rf50
C1518546 (UMLS CUI-1)
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])
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])
Code List
Off Study Reason
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])
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])

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