ID

3098

Descrição

AMC Clinical Trials - Gleevec Administration & Compliance Form for Protocol #042 - PR4202 Imatinib Mesylate in Treating Patients With HIV-Related Kaposi's Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EA0B255D-5729-3870-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EA0B255D-5729-3870-E034-0003BA3F9857

Palavras-chave

Versões (3)
  1. 19/09/2012 19/09/2012 - Philipp Bruland
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 27/06/2015 27/06/2015 -
Transferido a

19 de setembro de 2012

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Sarcoma NCT00090987 Treatment - AMC Clinical Trials - Gleevec Administration & Compliance Form for Protocol #042 - PR4202 - 2264834v3.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: AMC Clinical Trials - Gleevec Administration & Compliance Form for Protocol #042 - PR4202
    1. No Instruction available.
Unnamed 1
Descrição

Unnamed 1

Patient Initials
Descrição

PatientInitialsName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Patient Study ID
Descrição

PatientCoordinatingIdentifierNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Current Cycle Number
Descrição

TreatmentCurrentCourseNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25379
UMLS 2011AA Property
C0750729
Date of Evaluation
Descrição

LesionAssessmentDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25367
Date tablets returned/dispensed
Descrição

PillsRemainingDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25394
UMLS 2011AA ObjectClass
C0994475
NCI Thesaurus Property
C25649
UMLS 2011AA Property
C1527428
Number of Gleevec tablets returned
Descrição

Numberoftabletsreturned

Tipo de dados

text

Number of Gleevec tablets dispensed
Descrição

Numberoftabletsdispensed

Tipo de dados

text

Were there any dose modifications/omissions to protocol treatment during this cycle?
Descrição

DoseModificationInd

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C25256
UMLS 2011AA ObjectClass
C1265611
NCI Thesaurus Property
C25572
NCI Thesaurus ValueDomain
C25572
Were tablets returned at this visit?
Descrição

Weretabletsreturnedatthisvisit?

Tipo de dados

text

Were tablets dispensed at this visit?
Descrição

Weretabletsdispensedatthisvisit?

Tipo de dados

text

Dose assigned
Descrição

Doseassigned

Tipo de dados

text

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: AMC Clinical Trials - Gleevec Administration & Compliance Form for Protocol #042 - PR4202
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Unnamed 1
PatientInitialsName
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientCoordinatingIdentifierNumber
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
TreatmentCurrentCourseNumber
Item
Current Cycle Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
C0750729 (UMLS 2011AA Property)
LesionAssessmentDate
Item
Date of Evaluation
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
PillsRemainingDate
Item
Date tablets returned/dispensed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25394 (NCI Thesaurus ObjectClass)
C0994475 (UMLS 2011AA ObjectClass)
C25649 (NCI Thesaurus Property)
C1527428 (UMLS 2011AA Property)
Numberoftabletsreturned
Item
Number of Gleevec tablets returned
text
Numberoftabletsdispensed
Item
Number of Gleevec tablets dispensed
text
Item
Were there any dose modifications/omissions to protocol treatment during this cycle?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25256 (NCI Thesaurus ObjectClass)
C1265611 (UMLS 2011AA ObjectClass)
C25572 (NCI Thesaurus Property)
C25572 (NCI Thesaurus ValueDomain)
CL.4
Code List
Were there any dose modifications/omissions to protocol treatment during this cycle?
CL Item
Yes, Planned (i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)
CL Item
Yes, Unplanned (i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Were tablets returned at this visit?
text
CL.1
Code List
Were tablets returned at this visit?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Were tablets dispensed at this visit?
text
CL.2
Code List
Were tablets dispensed at this visit?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Dose assigned
text
CL.3
Code List
Dose assigned
CL Item
400 mg per day (400 mg per day)
CL Item
600 mg per day (600 mg per day)
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