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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

Lien

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

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 29/08/2017 29/08/2017 -
Téléchargé le

29 août 2017

DOI

Pour une demande vous connecter.

Licence

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

    Anglais

    No Instruction available.

    1 Formulaires  
    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

    Type de données

    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)

    Type de données

    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

    Type de données

    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

    Type de données

    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.)

    Type de données

    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

    Type de données

    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
    Retour au début de la page

    Similar models

    No Instruction available.

    1 Formulaires
    1. StudyEvent: AMC-064 Missed Visit Form (F35)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    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])
    Retour au début de la page 

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