ID

25268

Description

AMC-064 Missed Visit Form (F35) 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=7C993962-28AC-EDFE-E040-BB89AD43562B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7C993962-28AC-EDFE-E040-BB89AD43562B

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/29/17 8/29/17 -
Uploaded on

August 29, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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AMC-064 Missed Visit Form (F35)

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-064 Missed Visit Form (F35)
    1. No Instruction available.
Header - Missed Visit Form
Description

Header - Missed Visit Form

Alias
UMLS CUI-1
C1320722
UMLS CUI-2
C1512346
UMLS CUI-3
C3805387
UMLS CUI-4
C0019829
Visit number
Description

Visit number

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI [1]
C1549755
Missed Visit Information
Description

Missed Visit Information

Alias
UMLS CUI-1
C1512346
UMLS CUI-2
C1533716
UMLS CUI-3
C3805387
UMLS CUI-4
C0019829
Missed Visit Date
Description

PatientAbsentVisitDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C48190
NCI Thesaurus Property-2
C25716
UMLS CUI [1,1]
C1512346
UMLS CUI [1,2]
C0332197
UMLS CUI [1,3]
C0011008
Reason patient missed visit
Description

PatientAbsentVisitReason

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C48190
NCI Thesaurus Property-2
C25716
UMLS CUI [1,1]
C1512346
UMLS CUI [1,2]
C0332197
UMLS CUI [1,3]
C0392360
Other, specify
Description

PatientAbsentVisitSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C48190
NCI Thesaurus Property-2
C25716
UMLS CUI [1,1]
C1512346
UMLS CUI [1,2]
C0332197
UMLS CUI [1,3]
C0392360
Next visit scheduled
Description

PatientScheduleNextVisitInd-2 (Items missed will be made up at the new visit.)

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C53286
NCI Thesaurus Property-2
C25211
NCI Thesaurus Property-3
C25716
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1,1]
C0515681
UMLS CUI [1,2]
C1512346
Comments
Description

Comments

Alias
UMLS CUI-1
C0947611
UMLS CUI-2
C1512346
UMLS CUI-4
C3805387
UMLS CUI-5
C0019829
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1512346
UMLS CUI [2]
C3805387
UMLS CUI [3]
C0019829
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-064 Missed Visit Form (F35)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header - Missed Visit Form
C1320722 (UMLS CUI-1)
C1512346 (UMLS CUI-2)
C3805387 (UMLS CUI-3)
C0019829 (UMLS CUI-4)
Visit number
Item
Visit number
integer
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI [1])
Item Group
Missed Visit Information
C1512346 (UMLS CUI-1)
C1533716 (UMLS CUI-2)
C3805387 (UMLS CUI-3)
C0019829 (UMLS CUI-4)
Missed Visit
Item
Missed Visit Date
date
C25164 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C48190 (NCI Thesaurus Property)
C25716 (NCI Thesaurus Property-2)
C1512346 (UMLS CUI [1,1])
C0332197 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
Reason patient missed visit
integer
C25638 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C48190 (NCI Thesaurus Property)
C25716 (NCI Thesaurus Property-2)
C1512346 (UMLS CUI [1,1])
C0332197 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
CL.1
Code List
Reason patient missed visit
CL Item
Patient Forgot (1)
CL Item
Health Reasons (2)
CL Item
Patient Could Not Get Off Work (3)
CL Item
Patient Unable To Obtain Dependent Care (4)
CL Item
Patient Had Transportation Problems (5)
CL Item
Patient Unhappy With Frequency Of Visits (6)
CL Item
Scheduling Difficulties (7)
CL Item
Patient Decided To Discontinue Study (8)
CL Item
Patient Experienced An Adverse Event (9)
CL Item
Other (10)
Other, specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C48190 (NCI Thesaurus Property)
C25716 (NCI Thesaurus Property-2)
C1512346 (UMLS CUI [1,1])
C0332197 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Next visit scheduled
Item
Next visit scheduled
text
C16960 (NCI Thesaurus ObjectClass)
C53286 (NCI Thesaurus Property)
C25211 (NCI Thesaurus Property-2)
C25716 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C0515681 (UMLS CUI [1,1])
C1512346 (UMLS CUI [1,2])
Item Group
Comments
C0947611 (UMLS CUI-1)
C1512346 (UMLS CUI-2)
C3805387 (UMLS CUI-4)
C0019829 (UMLS CUI-5)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1,1])
C1512346 (UMLS CUI [1,2])
C3805387 (UMLS CUI [2])
C0019829 (UMLS CUI [3])
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