0 Ratings
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

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

  • Newest
  • Oldest
  • Popular
  • Newest
    • Newest
    • Oldest
    • Popular

    No comments

    In order to download data models you must be logged in. Please log in or register for free.

    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
    Back to the top of the page

    Similar models

    No Instruction available.

    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)
    Back to the top of the page 

    Help

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial