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ID

2728

Description

The Division of Cancer Prevention's physical exam (continued) case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C120DDA-54D8-39FD-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C120DDA-54D8-39FD-E044-0003BA3F9857

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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September 19, 2012

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Creative Commons BY-NC 3.0 Legacy
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    On-Study - Physical Exam (continued) - 2803398v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Physical Exam (continued)
      1. No Instruction available.
    Screening
    Description

    Screening

    DCP Protocol #
    Description

    ProtocolNCIIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property
    C19202 (undefined)
    UMLS 2011AA Property
    C1513882 (National Cancer Institute)
    LOINC
    LA4524-0
    Institution Code
    Description

    NationalCancerInstituteInstituteCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS 2011AA ValueDomain
    C0805701 (Code)
    NCI Thesaurus ObjectClass
    C21541 (undefined)
    UMLS 2011AA ObjectClass
    C0018704 (Health care facility)
    SNOMED
    257622000
    LOINC
    LA30302-6
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    Participant ID
    Description

    ParticipantIdentifier

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ValueDomain
    C25364 (undefined)
    UMLS 2011AA ValueDomain
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    Visit Type
    Description

    VisitTypeText

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25284 (undefined)
    UMLS 2011AA Property
    C0332307 (Type - attribute)
    SNOMED
    261664005
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ObjectClass
    C25716 (undefined)
    UMLS 2011AA ObjectClass
    C0545082 (Visit)
    Visit Date
    Description

    VisitDate

    Data type

    date

    Alias
    NCI Thesaurus Property
    C25164 (undefined)
    UMLS 2011AA Property
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain
    C25367 (undefined)
    NCI Thesaurus ObjectClass
    C25716 (undefined)
    UMLS 2011AA ObjectClass
    C0545082 (Visit)
    Baseline Medical/surgical History
    Description

    Baseline Medical/surgical History

    Specify Other Body System/Site
    Description

    OtherBodySystem/SiteText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ObjectClass
    C13041 (undefined)
    UMLS 2011AA ObjectClass
    C1268086 (Body structure)
    SNOMED
    123037004
    LOINC
    LP28569-9
    NCI Thesaurus Property
    C25700 (undefined)
    UMLS 2011AA Property
    C0449913 (System)
    SNOMED
    246333005
    Body System
    Description

    BodySystemIndicator

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C13041 (undefined)
    UMLS 2011AA ObjectClass
    C1268086 (Body structure)
    SNOMED
    123037004
    LOINC
    LP28569-9
    NCI Thesaurus Property
    C25700 (undefined)
    UMLS 2011AA Property
    C0449913 (System)
    SNOMED
    246333005
    NCI Metathesaurus ValueDomain
    C0021212 (Indicators)
    Comment (Required if Abnormal) (Provide condition/diagnosis)
    Description

    AbnormalCommentText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ObjectClass
    C25393 (undefined)
    UMLS 2011AA ObjectClass
    C0282411 (Published Comment)
    LOINC
    MTHU018874
    NCI Thesaurus Property
    C25365 (undefined)
    UMLS 2011AA Property
    C0678257 (Description)
    LOINC
    LP6800-9
    Dcp Template Footer
    Description

    Dcp Template Footer

    Protocol Title
    Description

    ProtocolTitleName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C42774 (undefined)
    UMLS 2011AA Property
    C1705823 (Object Title)
    Protocol Version
    Description

    ProtocolVersion

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    Protocol Date
    Description

    ProtocolVersionDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ValueDomain
    C25367 (undefined)
    Page #
    Description

    PageNumber

    Data type

    double

    Alias
    NCI Thesaurus Property
    C25337 (undefined)
    UMLS 2011AA Property
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Metathesaurus ObjectClass
    C0439643 (Sheets (formation))
    SNOMED
    255292000
    Total Page Number
    Description

    CaseReportFormTotalPageNumber

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C40988 (undefined)
    UMLS 2011AA ObjectClass
    C1516308 (Case Report Form)
    NCI Thesaurus Property
    C25337 (undefined)
    UMLS 2011AA Property
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus Property
    C25304 (undefined)
    UMLS 2011AA Property
    C0439810 (Total)
    SNOMED
    255619001
    LOINC
    LP21089-5
    NCI Thesaurus Property
    C42783 (undefined)
    UMLS 2011AA Property
    C1704732 (Page (document))
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    DCP Template Version
    Description

    DCPTemplateVersionText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Metathesaurus ObjectClass
    C0728990 (Clinical Use Template)
    NCI Thesaurus Property
    C25714 (undefined)
    UMLS 2011AA Property
    C0333052 (Version)
    LOINC
    MTHU010265
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: Physical Exam (continued)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Screening
    ProtocolNCIIdentifierNumber
    Item
    DCP Protocol #
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C19202 (NCI Thesaurus Property)
    C1513882 (UMLS 2011AA Property)
    NationalCancerInstituteInstituteCode
    Item
    Institution Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ParticipantIdentifier
    Item
    Participant ID
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus ValueDomain)
    C0600091 (UMLS 2011AA ValueDomain)
    VisitTypeText
    Item
    Visit Type
    text
    C25284 (NCI Thesaurus Property)
    C0332307 (UMLS 2011AA Property)
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25716 (NCI Thesaurus ObjectClass)
    C0545082 (UMLS 2011AA ObjectClass)
    VisitDate
    Item
    Visit Date
    date
    C25164 (NCI Thesaurus Property)
    C0011008 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    C25716 (NCI Thesaurus ObjectClass)
    C0545082 (UMLS 2011AA ObjectClass)
    Item Group
    Baseline Medical/surgical History
    OtherBodySystem/SiteText
    Item
    Specify Other Body System/Site
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C13041 (NCI Thesaurus ObjectClass)
    C1268086 (UMLS 2011AA ObjectClass)
    C25700 (NCI Thesaurus Property)
    C0449913 (UMLS 2011AA Property)
    Item
    Body System
    text
    C13041 (NCI Thesaurus ObjectClass)
    C1268086 (UMLS 2011AA ObjectClass)
    C25700 (NCI Thesaurus Property)
    C0449913 (UMLS 2011AA Property)
    C0021212 (NCI Metathesaurus ValueDomain)
    CL.1
    Code List
    Body System
    CL Item
    Abnormal (Abnormal)
    C25401 (NCI Thesaurus)
    C0205161 (UMLS 2011AA)
    CL Item
    Normal (Normal)
    C14165 (NCI Thesaurus)
    C0205307 (UMLS 2011AA)
    AbnormalCommentText
    Item
    Comment (Required if Abnormal) (Provide condition/diagnosis)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25393 (NCI Thesaurus ObjectClass)
    C0282411 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    Item Group
    Dcp Template Footer
    ProtocolTitleName
    Item
    Protocol Title
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C42774 (NCI Thesaurus Property)
    C1705823 (UMLS 2011AA Property)
    ProtocolVersion
    Item
    Protocol Version
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolVersionDate
    Item
    Protocol Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain)
    PageNumber
    Item
    Page #
    double
    C25337 (NCI Thesaurus Property)
    C0237753 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C0439643 (NCI Metathesaurus ObjectClass)
    CaseReportFormTotalPageNumber
    Item
    Total Page Number
    text
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C25337 (NCI Thesaurus Property)
    C0237753 (UMLS 2011AA Property)
    C25304 (NCI Thesaurus Property)
    C0439810 (UMLS 2011AA Property)
    C42783 (NCI Thesaurus Property)
    C1704732 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    DCPTemplateVersionText
    Item
    DCP Template Version
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C0728990 (NCI Metathesaurus ObjectClass)
    C25714 (NCI Thesaurus Property)
    C0333052 (UMLS 2011AA Property)
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