ID

26140

Description

Course Initiation form for C3D 3.12 Adopters Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0175BCA0-5585-5F61-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0175BCA0-5585-5F61-E044-0003BA3F9857

Keywords

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

National Cancer Institute

Uploaded on

October 9, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Course Initiation form

English

Dates will appear as 'DD-MON-YYYY'

1 forms  
  1. StudyEvent: COURSE INITIATION
    1. Dates will appear as 'DD-MON-YYYY'
Course Initiation
Description

Course Initiation

Alias
UMLS CUI-1
C0750729
UMLS CUI-2
C1704686
UMLS CUI-3
C0087111
Course Number
Description

Course Number

Data type

integer

Alias
NCI Thesaurus Property
C25337
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C25379
UMLS CUI [1,1]
C0750729
UMLS CUI [1,2]
C0237753
Course Start Date
Description

CourseStartDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25379
NCI Metathesaurus ObjectClass
CL219258
NCI Thesaurus Property
C25164
NCI Thesaurus Property-2
C25431
NCI Thesaurus ValueDomain
C25164
UMLS CUI [1,1]
C0750729
UMLS CUI [1,2]
C0808070
Treatment Arm
Description

Treatment Arm

Data type

text

Alias
NCI Thesaurus ObjectClass
C32141
NCI Thesaurus ObjectClass-2
C42651
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus Property
C25426
UMLS CUI [1]
C1522541
Treatment Assignment Code at Enrollment
Description

EnrollmentTreatmentStudyAssignmentCode

Data type

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C19992
NCI Thesaurus Property
C25162
NCI Thesaurus Property-2
C25426
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus ValueDomain-2
C37948
NCI Thesaurus ValueDomain-3
C25426
NCI Thesaurus ValueDomain-4
C49656
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0805701
Treating Institution Text Code
Description

Treating Institution Text Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus ObjectClass
C25705
NCI Thesaurus ObjectClass-2
C19992
NCI Metathesaurus Property
CL281747
UMLS CUI [1,1]
C0018704
UMLS CUI [1,2]
C0805701
Stop Date
Description

End Date

Data type

date

Alias
NCI Thesaurus Property
C25164
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property-2
C65125
UMLS CUI [1,1]
C0750729
UMLS CUI [1,2]
C0806020
Vital Signs
Description

Vital Signs

Alias
UMLS CUI-1
C0518766
Evaluation Date
Description

Evaluation Date

Data type

date

Alias
NCI Thesaurus Property
C25164
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25214
UMLS CUI [1,1]
C0220825
UMLS CUI [1,2]
C0011008
Lab Collection Time
Description

Collection Time

Data type

time

Alias
NCI Thesaurus Property
C25453
NCI Thesaurus Property-2
C25207
NCI Thesaurus ValueDomain
C25207
NCI Thesaurus ObjectClass
C25294
UMLS CUI [1]
C4064021
Height
Description

Height

Data type

float

Measurement units
  • cm
Alias
NCI Thesaurus ValueDomain
C25209
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25347
UMLS CUI [1]
C0489786
cm
Body Weight in Kilograms
Description

Weight

Data type

float

Measurement units
  • Kg
Alias
NCI Thesaurus ValueDomain
C25209
NCI Thesaurus ObjectClass
C13041
NCI Thesaurus Property
C25208
UMLS CUI [1]
C0005910
Kg
BSA
Description

Body Surface Area

Data type

float

Measurement units
  • m2
Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus Property
C25157
UMLS CUI [1]
C0005902
m2
Zubrod Performance Status Score
Description

Zubrod Performance Status Score

Data type

text

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C20641
NCI Thesaurus ValueDomain
C25338
UMLS CUI [1]
C3714786
Karnofsky Performance Status Score
Description

Karnofsky Performance Status Score

Data type

text

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C20641
NCI Thesaurus ValueDomain
C25338
UMLS CUI [1]
C0206065
Lansky Performance Status Score
Description

Lansky Performance Status Score

Data type

text

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C20641
NCI Thesaurus ValueDomain
C25338
UMLS CUI [1]
C1522275
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Similar models

Dates will appear as 'DD-MON-YYYY'

1 forms
  1. StudyEvent: COURSE INITIATION
    1. Dates will appear as 'DD-MON-YYYY'
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Course Initiation
C0750729 (UMLS CUI-1)
C1704686 (UMLS CUI-2)
C0087111 (UMLS CUI-3)
Course Number
Item
Course Number
integer
C25337 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C25379 (NCI Thesaurus ObjectClass)
C0750729 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Course Start Date
Item
Course Start Date
date
C25379 (NCI Thesaurus ObjectClass)
CL219258 (NCI Metathesaurus ObjectClass)
C25164 (NCI Thesaurus Property)
C25431 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0750729 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Treatment Arm
Item
Treatment Arm
text
C32141 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C25712 (NCI Thesaurus ValueDomain)
C25426 (NCI Thesaurus Property)
C1522541 (UMLS CUI [1])
Treatment Assignment Code
Item
Treatment Assignment Code at Enrollment
text
C15368 (NCI Thesaurus ObjectClass)
C19992 (NCI Thesaurus ObjectClass-2)
C25162 (NCI Thesaurus Property)
C25426 (NCI Thesaurus Property-2)
C25162 (NCI Thesaurus ValueDomain)
C37948 (NCI Thesaurus ValueDomain-2)
C25426 (NCI Thesaurus ValueDomain-3)
C49656 (NCI Thesaurus ValueDomain-4)
C0087111 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
Treating Institution Text Code
Item
Treating Institution Text Code
text
C25162 (NCI Thesaurus ValueDomain)
C25705 (NCI Thesaurus ObjectClass)
C19992 (NCI Thesaurus ObjectClass-2)
CL281747 (NCI Metathesaurus Property)
C0018704 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
End Date
Item
Stop Date
date
C25164 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C65125 (NCI Thesaurus Property-2)
C0750729 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Item Group
Vital Signs
C0518766 (UMLS CUI-1)
Evaluation Date
Item
Evaluation Date
date
C25164 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Collection Time
Item
Lab Collection Time
time
C25453 (NCI Thesaurus Property)
C25207 (NCI Thesaurus Property-2)
C25207 (NCI Thesaurus ValueDomain)
C25294 (NCI Thesaurus ObjectClass)
C4064021 (UMLS CUI [1])
Height
Item
Height
float
C25209 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS CUI [1])
Weight
Item
Body Weight in Kilograms
float
C25209 (NCI Thesaurus ValueDomain)
C13041 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
C0005910 (UMLS CUI [1])
Body Surface Area
Item
BSA
float
C25190 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS CUI [1])
Item
Zubrod Performance Status Score
text
C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C3714786 (UMLS CUI [1])
CL.1
Code List
Zubrod Performance Status Score
CL Item
Normal Activity (0)
CL Item
Symptoms, But Nearly Fully Ambulatory (1)
CL Item
Some Bed Time, But Needs To Be In Bed <50% Of Normal Daytime (2)
CL Item
Needs To Be In Bed > 50% Of Normal Daytime (3)
CL Item
Unable To Get Out Of Bed (4)
Item
Karnofsky Performance Status Score
text
C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C0206065 (UMLS CUI [1])
CL.2
Code List
Karnofsky Performance Status Score
CL Item
Dead (0)
CL Item
Moribund, Fatal Processes Progressing Rapidly (10)
CL Item
Normal, No Complaints, No Evidence Of Disease (100)
CL Item
Very Sick, Hospitalization Indicated. Death Not Imminent (20)
CL Item
Severely Disabled, Hospitalization Indicated. Death Not Imminent (30)
CL Item
Disabled, Requires Special Care And Assistance (40)
CL Item
Requires Considerable Assistance And Frequent Medical Care (50)
CL Item
Requires Occasional Assistance, But Is Able To Care For Most Of His/her Needs (60)
CL Item
Cares For Self, Unable To Carry On Normal Activity Or To Do Active Work (70)
CL Item
Normal Activity With Effort; Some Signs Or Symptoms Of Disease (80)
CL Item
Able To Carry On Normal Activity; Minor Signs Or Symptoms Of Disease (90)
Item
Lansky Performance Status Score
text
C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C1522275 (UMLS CUI [1])
CL.3
Code List
Lansky Performance Status Score
CL Item
Unresponsive (0)
CL Item
No Play; Does Not Get Out Of Bed. (10)
CL Item
Fully Active, Normal (100)
CL Item
Often Sleeping; Play Entirely Limited To Very Passive Activities. (20)
CL Item
In Bed; Needs Assistance Even For Quiet Play. (30)
CL Item
Mostly In Bed; Participates In Quiet Activities. (40)
CL Item
Gets Dressed, But Lies Around Much Of The Day; No Active Play, Able To Participate In All Quiet Play And Activities. (50)
CL Item
Up And Around, But Minimal Active Play; Keeps Busy With Quieter Activities. (60)
CL Item
Both Greater Restriction Of And Less Time Spent In Play Activity (70)
CL Item
Active, But Tires More Quickly (80)
CL Item
Minor Restrictions In Physically Strenuous Activity (90)
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