ID

26130

Description

AMC-063 Missed Visit Form (F35) Bortezomib in Treating Patients With Relapsed or Refractory AIDS-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=815FD129-E16B-59A5-E040-BB89AD431E71

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=815FD129-E16B-59A5-E040-BB89AD431E71

Keywords

Versions (1)
  1. 10/9/17 10/9/17 -
Copyright Holder

AIDS Malignancy Consortium

Uploaded on

October 9, 2017

DOI

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License

Creative Commons BY-NC 3.0
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AMC-063 Missed Visit Form (F35)

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-063 Missed Visit Form (F35)
    1. No Instruction available.
Header - Missed Visit Form (F35)
Description

Header - Missed Visit Form (F35)

Alias
UMLS CUI-1
C1320722
UMLS CUI-2
C1512346
UMLS CUI-3
C0276535
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
C1705492
UMLS CUI-3
C1533716
UMLS CUI-4
C0276535
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]
C1705492
UMLS CUI [1,3]
C0011008
Reason patient missed visit
Description

PatientAbsentVisitReason

Data type

text

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]
C1705492
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]
C1705492
UMLS CUI [1,3]
C0392360
Next visit scheduled
Description

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

Data type

boolean

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
C0276535
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]
C0276535
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No Instruction available.

1 forms
  1. StudyEvent: AMC-063 Missed Visit Form (F35)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header - Missed Visit Form (F35)
C1320722 (UMLS CUI-1)
C1512346 (UMLS CUI-2)
C0276535 (UMLS CUI-3)
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)
C1705492 (UMLS CUI-2)
C1533716 (UMLS CUI-3)
C0276535 (UMLS CUI-4)
Missed Visit Date
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])
C1705492 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
Reason patient missed visit
text
C25638 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C48190 (NCI Thesaurus Property)
C25716 (NCI Thesaurus Property-2)
C1512346 (UMLS CUI [1,1])
C1705492 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
CL.1
Code List
Reason patient missed visit
CL Item
Patient Forgot (Patient forgot)
CL Item
Health Reasons (Health reasons)
CL Item
Patient Could Not Get Off Work (Patient could not get off work)
CL Item
Patient Unable To Obtain Dependent Care (Patient unable to obtain dependent care)
CL Item
Patient Had Transportation Problems (Patient had transportation problems)
CL Item
Patient Unhappy With Frequency Of Visits (Patient unhappy with frequency of visits)
CL Item
Scheduling Difficulties (Scheduling difficulties)
CL Item
Patient Decided To Discontinue Study (Patient decided to discontinue study)
CL Item
Patient Experienced An Adverse Event (Patient experienced an Adverse Event)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Reason patient missed visit
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])
C1705492 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Next visit scheduled
Item
Next visit scheduled
boolean
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)
C0276535 (UMLS CUI-2)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1,1])
C0276535 (UMLS CUI [1,2])
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