ID

2914

Description

AMC-051 Missed Visit Form (F35) Sirolimus in Treating Patients With HIV-Related Kaposi's Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=2FDFA89A-0842-6018-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=2FDFA89A-0842-6018-E044-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 6/1/15 6/1/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Sarcoma NCT00450320 Follow-Up - AMC-051 Missed Visit Form (F35) - 2636138v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-051 Missed Visit Form (F35)
    1. No Instruction available.
Unnamed1
Description

Unnamed1

Visit number
Description

HospitalAdmissionOrdinalNumber

Data type

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16696
UMLS 2011AA ObjectClass
C0019994
NCI Thesaurus Property
C25385
UMLS 2011AA Property
C0809949
Unnamed2
Description

Unnamed2

Missed Visit Date
Description

PatientAbsentVisitDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property
C25716
UMLS 2011AA Property
C0545082
Reason patient missed visit
Description

PatientAbsentVisitReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property
C25716
UMLS 2011AA Property
C0545082
Other, specify
Description

PatientAbsentVisitSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property
C25716
UMLS 2011AA Property
C0545082
Next visit scheduled
Description

PatientScheduleNextVisitInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C53286
UMLS 2011AA Property
C0332282
NCI Thesaurus Property
C25211
UMLS 2011AA Property
C0086960
NCI Thesaurus Property
C25716
UMLS 2011AA Property
C0545082
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Comments
Description

Comments

Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
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No Instruction available.

1 forms
  1. StudyEvent: AMC-051 Missed Visit Form (F35)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
HospitalAdmissionOrdinalNumber
Item
Visit number
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25385 (NCI Thesaurus Property)
C0809949 (UMLS 2011AA Property)
Item Group
Unnamed2
PatientAbsentVisitDate
Item
Missed Visit Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
Item
Reason patient missed visit
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
CL.1
Code List
Reason patient missed visit
CL Item
Patient Had Transportation Problems (Patient had transportation problems)
CL Item
Health Reasons (Health reasons)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Patient Could Not Get Off Work (Patient could not get off work)
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
Patient Forgot (Patient forgot)
CL Item
Patient Unable To Obtain Dependent Care (Patient unable to obtain dependent care)
CL Item
Patient Unhappy With Frequency Of Visits (Patient unhappy with frequency of visits)
CL Item
Scheduling Difficulties (Scheduling difficulties)
PatientAbsentVisitSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
Item
Next visit scheduled
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C53286 (NCI Thesaurus Property)
C0332282 (UMLS 2011AA Property)
C25211 (NCI Thesaurus Property)
C0086960 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.2
Code List
Next visit scheduled
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Comments
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
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