ID

2998

Description

The Division of Cancer Prevention's intervention administration (blinded study) case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C0DAF39-FA2E-52F4-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C0DAF39-FA2E-52F4-E044-0003BA3F9857

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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On-Study - Intervention Administration (Blinded Study) - 2802926v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Intervention Administration (Blinded Study)
    1. No Instruction available.
Screening
Description

Screening

DCP Protocol #
Description

ProtocolNCIIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C19202
UMLS 2011AA Property
C1513882
Institution Code
Description

NationalCancerInstituteInstituteCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant ID
Description

ParticipantIdentifier

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25364
UMLS 2011AA ValueDomain
C0600091
Visit Type
Description

VisitTypeText

Data type

text

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Visit Date
Description

VisitDate

Data type

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Intervention Administration (blinded Study)
Description

Intervention Administration (blinded Study)

Agent #
Description

AgentAdministrationNumber

Data type

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain
C1708
UMLS 2011AA ValueDomain
C0450442
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
Agent/Placebo
Description

AgentName

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain
C1708
UMLS 2011AA ValueDomain
C0450442
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
Dose
Description

AgentDose

Data type

double

Alias
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus Property
C25417
NCI Thesaurus ValueDomain
C25417
Dose Units
Description

DosageUnitofMeasureCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass
C25274
UMLS 2011AA ObjectClass
C0237400
NCI Thesaurus Property
C25709
UMLS 2011AA Property
C1519795
Frequency
Description

DoseFrequencyCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C25488
UMLS 2011AA Property
C0178602
NCI Thesaurus ObjectClass
C25515
UMLS 2011AA ObjectClass
C0439603
Date Agent Provided (to participant MM/DD/YYYY)
Description

AgentProvidedtoParticipantDate

Data type

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
Agent Start Date (MM/DD/YYYY)
Description

AgentBeginDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25431
UMLS 2011AA ValueDomain
C0439659
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Dcp Template Footer
Description

Dcp Template Footer

Protocol Title
Description

ProtocolTitleName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C42774
UMLS 2011AA Property
C1705823
Protocol Version
Description

ProtocolVersion

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Protocol Date
Description

ProtocolVersionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25367
Page #
Description

PageNumber

Data type

double

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Metathesaurus ObjectClass
C0439643
Total Number of Pages in CRF
Description

CaseReportFormTotalPageNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus Property
C25304
UMLS 2011AA Property
C0439810
NCI Thesaurus Property
C42783
UMLS 2011AA Property
C1704732
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
DCP Template Version
Description

DCPTemplateVersionText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Metathesaurus ObjectClass
C0728990
NCI Thesaurus Property
C25714
UMLS 2011AA Property
C0333052
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1 forms
  1. StudyEvent: Intervention Administration (Blinded Study)
    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
Intervention Administration (blinded Study)
AgentAdministrationNumber
Item
Agent #
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C0450442 (UMLS 2011AA ValueDomain)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
AgentName
Item
Agent/Placebo
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C0450442 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
AgentDose
Item
Dose
double
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25417 (NCI Thesaurus Property)
C25417 (NCI Thesaurus ValueDomain)
Item
Dose Units
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25274 (NCI Thesaurus ObjectClass)
C0237400 (UMLS 2011AA ObjectClass)
C25709 (NCI Thesaurus Property)
C1519795 (UMLS 2011AA Property)
CL.1
Code List
Dose Units
CL Item
Percent (%)
C48570 (NCI Thesaurus)
C0439165 (UMLS 2011AA)
CL Item
Application (app)
C25397 (NCI Thesaurus)
C0185125 (UMLS 2011AA)
CL Item
Becquerel (Bq)
CL Item
Capsule (Cap)
C25158 (NCI Thesaurus)
C0006935 (UMLS 2011AA)
CL Item
Curie (Ci)
C0700085 (NCI Metathesaurus)
CL Item
Caplet (Cplt)
C64696 (NCI Thesaurus)
C1879996 (UMLS 2011AA)
CL Item
Dram (DF)
CL Item
Gram (G)
C48155 (NCI Thesaurus)
C0439208 (UMLS 2011AA)
CL Item
Gigabequerel (GBq)
CL Item
Drop (gtt)
CL Item
International Unit (iu)
C28255 (NCI Thesaurus)
CL Item
International Unit Per Kilogram (iu/kg)
CL Item
Joule Per Centimeter Squared (J/cm2)
CL Item
Kilobecquerel (KBq)
CL Item
Kilogram (kg)
C28252 (NCI Thesaurus)
C0439209 (UMLS 2011AA)
CL Item
Thousand International Unit (kiu)
CL Item
Liter (l)
CL Item
Megabequerel (MBq)
CL Item
Millicurie (mCi)
CL Item
Milliequivalent (mEq)
CL Item
Milligram (mg)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
CL Item
Milligram Per Kilogram (mg/kg)
CL Item
Milligram Per Square Meter (mg/m2)
CL Item
Milli-international Unit (Miu)
CL Item
Milliliter (mL)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Milliliter (ML)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Millimole (mmol)
CL Item
Mole (mol)
CL Item
Nanocurie (nCi)
C0560007 (NCI Metathesaurus)
CL Item
Nanogram (ng)
CL Item
Other (Oth)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Picogram (PG)
C64551 (NCI Thesaurus)
C0439213 (UMLS 2011AA)
CL Item
Puff Dosing Unit (Puff)
C65060 (NCI Thesaurus)
C1533107 (UMLS 2011AA)
CL Item
Sachet Dosing Unit (Sachet)
C71324 (NCI Thesaurus)
C2348127 (UMLS 2011AA)
CL Item
Tablet (Tab)
CL Item
Tablespoon Dosing Unit (tbs)
C48541 (NCI Thesaurus)
C1532188 (UMLS 2011AA)
CL Item
Teaspoon Dosing Unit (tsp)
C48544 (NCI Thesaurus)
C1704619 (UMLS 2011AA)
CL Item
Microcurie (uCi)
CL Item
Microgram (ug)
CL Item
Microgram Per Kilogram (ug/kg)
CL Item
Microgram Per Square Meter (ug/m2)
CL Item
Microliter (UL)
C48153 (NCI Thesaurus)
C0439243 (UMLS 2011AA)
CL Item
Micromole (UMOL)
C48509 (NCI Thesaurus)
C0439194 (UMLS 2011AA)
CL Item
Unit Dose (Units)
C65135 (NCI Thesaurus)
C0869039 (UMLS 2011AA)
CL Item
Unknown (Unk)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DoseFrequencyCode
Item
Frequency
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus Property)
C0178602 (UMLS 2011AA Property)
C25515 (NCI Thesaurus ObjectClass)
C0439603 (UMLS 2011AA ObjectClass)
AgentProvidedtoParticipantDate
Item
Date Agent Provided (to participant MM/DD/YYYY)
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
AgentBeginDate
Item
Agent Start Date (MM/DD/YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (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 Number of Pages in CRF
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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