ID

3155

Descrição

AMC-070 Missed Visit Form (F35) Lenalidomide in Treating Patients With AIDS-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=91E448E8-A121-E89F-E040-BB89AD433766

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=91E448E8-A121-E89F-E040-BB89AD433766

Palavras-chave

Versões (1)
  1. 19/09/2012 19/09/2012 -
Transferido a

19 de setembro de 2012

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Nonneoplastic Condition NCT01057121 Follow-Up - AMC-070 Missed Visit Form (F35) - 3147075v1.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: AMC-070 Missed Visit Form (F35)
    1. No Instruction available.
Unnamed1
Descrição

Unnamed1

Visit number
Descrição

HospitalAdmissionOrdinalNumber

Tipo de dados

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
Descrição

Unnamed2

Missed Visit Date (mm/dd/yyyy)
Descrição

PatientAbsentVisitDate

Tipo de dados

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
Descrição

PatientAbsentVisitReason

Tipo de dados

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
Descrição

PatientAbsentVisitSpecify

Tipo de dados

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 (Items missed will be made up at the new visit.)
Descrição

PatientScheduleNextVisitInd-2

Tipo de dados

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
Descrição

Comments

Comments
Descrição

ResearchCommentsText

Tipo de dados

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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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: AMC-070 Missed Visit Form (F35)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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 (mm/dd/yyyy)
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 Forgot (Patient forgot)
CL Item
Health Reasons (Health reasons)
CL Item
Patient Could Not Get Off Work (Patient could not get off work)
CL Item
Patient Unable To Obtain Dependent Care (Patient unable to obtain dependent care)
CL Item
Patient Had Transportation Problems (Patient had transportation problems)
CL Item
Patient Unhappy With Frequency Of Visits (Patient unhappy with frequency of visits)
CL Item
Scheduling Difficulties (Scheduling difficulties)
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
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
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 (Items missed will be made up at the new visit.)
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 (Items missed will be made up at the new visit.)
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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