ID

3222

Beschrijving

Eligibility Form for Protocol #040 - PR4001 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=CCE1F242-913A-4391-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=CCE1F242-913A-4391-E034-0003BA12F5E7

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 09-01-15 09-01-15 - Martin Dugas
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19 september 2012

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Creative Commons BY-NC 3.0 Legacy
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Sarcoma, Kaposi xxx Eligibility - Eligibility Form for Protocol #040 - PR4001 - 2266387v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Eligibility Form for Protocol #040 - PR4001
    1. No Instruction available.
Ccrr Module For Eligibility Form For Protocol #040 - Pr4001
Beschrijving

Ccrr Module For Eligibility Form For Protocol #040 - Pr4001

Patient Initials
Beschrijving

PatientInitialsName

Datatype

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
Study#
Beschrijving

ProtocolCoordinatingIdentifierNumber

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Site#
Beschrijving

NCIInstitutionIdentifierCode

Datatype

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
NCI Thesaurus ObjectClass
C19202
UMLS 2011AA ObjectClass
C1513882
ID#
Beschrijving

PatientCoordinatingIdentifierNumber

Datatype

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
Visit Date
Beschrijving

Dateofassessment

Datatype

text

Does the patient have biopsy proven KS involving the skin, lymph nodes, oral cavity, gastrointestinal (GI) tract and/or lungs?
Beschrijving

DoesthepatienthavebiopsyprovenKSinvolvingtheskin,lymphnodes,oralcavity,gastrointestinal(GI)tractand/orlungs?

Datatype

text

Does the patient have Serologic documentation of HIV infection 21 days prior to study entry, as evidenced by positive ELISA, positive Western Blot, or other federally approved licensed HIV test?
Beschrijving

DoesthepatienthaveSerologicdocumentationofHIVinfection21dayspriortostudyentry,asevidencedbypositiveELISA,positiveWesternBlot,orotherfederallyapprovedlicensedHIVtest?

Datatype

text

Is patient's baseline Karnofsky performance status >60%?
Beschrijving

Ispatient'sbaselineKarnofskyperformancestatus>60%?

Datatype

text

Is patient's hemoglobin > 8 g/dl within 7 days of study entry?
Beschrijving

Ispatient'shemoglobin>8g/dlwithin7daysofstudyentry?

Datatype

text

Is patient's absolute neutrophil count > 1500 cells/mm3 and platelets > 100,000 cells/mm3 within 7 days of study entry?
Beschrijving

Ispatient'sabsoluteneutrophilcount>1500cells/mm3andplatelets>100,000cells/mm3within7daysofstudyentry?

Datatype

text

Is patient's creatinine < 1.5 times the upper limit of normal within 7 days of study entry?
Beschrijving

Ispatient'screatinine<1.5timestheupperlimitofnormalwithin7daysofstudyentry?

Datatype

text

Is patient's total bilirubin <1.5x ULN within 7 days of study entry?
Beschrijving

Ispatient'stotalbilirubin<1.5xULNwithin7daysofstudyentry?

Datatype

text

Is patient's AST (SGOT) and ALT (SGPT) < 3 x the upper limit of normal within 7 days of study entry?
Beschrijving

Ispatient'sAST(SGOT)andALT(SGPT)<3xtheupperlimitofnormalwithin7daysofstudyentry?

Datatype

text

Is patient's life expectancy > 3 months?
Beschrijving

Ispatient'slifeexpectancy>3months?

Datatype

text

Is the patient age of 18 or older?
Beschrijving

Isthepatientageof18orolder?

Datatype

text

Does the patient have ability and willingness to give informed consent?
Beschrijving

Doesthepatienthaveabilityandwillingnesstogiveinformedconsent?

Datatype

text

If female capable of childbearing, has the patient had a negative serum B-HCG within 72 hours prior to study entry?
Beschrijving

Iffemalecapableofchildbearing,hasthepatienthadanegativeserumB-HCGwithin72hourspriortostudyentry?

Datatype

text

If female capable of childbearing, does the patient agree to practice adequate birth control to prevent pregnancy while receiving treatment and for three months after treatment is discontinued?
Beschrijving

Iffemalecapableofchildbearing,doesthepatientagreetopracticeadequatebirthcontroltopreventpregnancywhilereceivingtreatmentandforthreemonthsaftertreatmentisdiscontinued?

Datatype

text

If female, is the patient breast feeding?
Beschrijving

Iffemale,isthepatientbreastfeeding?

Datatype

text

If male of child fathering potential, does the patient agree to practice adequate birth control?
Beschrijving

Ifmaleofchildfatheringpotential,doesthepatientagreetopracticeadequatebirthcontrol?

Datatype

text

In the opinion of the investigator, is the patient capable of complying with the protocol?
Beschrijving

Intheopinionoftheinvestigator,isthepatientcapableofcomplyingwiththeprotocol?

Datatype

text

If patient is receiving antiretroviral therapy, is the patient on a stable regimen for at least 4 weeks prior to study entry?
Beschrijving

Ifpatientisreceivingantiretroviraltherapy,isthepatientonastableregimenforatleast4weekspriortostudyentry?

Datatype

text

Does the patient have concurrent, acute, active opportunistic infection other than oral thrush or genital herpes within 14 days of enrollment?
Beschrijving

Doesthepatienthaveconcurrent,acute,activeopportunisticinfectionotherthanoralthrushorgenitalherpeswithin14daysofenrollment?

Datatype

text

Does the patient have symptomatic visceral Kaposi's Sarcoma requiring cytotoxic therapy unless the patient has already been shown to be refractory to or intolerant of all currently approved agents for visceral Kaposi's Sarcoma?
Beschrijving

DoesthepatienthavesymptomaticvisceralKaposi'sSarcomarequiringcytotoxictherapyunlessthepatienthasalreadybeenshowntoberefractorytoorintolerantofallcurrentlyapprovedagentsforvisceralKaposi'sSarcoma?

Datatype

text

Does the patient have concurrent neoplasia requiring cytotoxic therapy?
Beschrijving

Doesthepatienthaveconcurrentneoplasiarequiringcytotoxictherapy?

Datatype

text

Has the patient had acute treatment for an infection (other than oral thrush or genital herpes) or other serious medical illness within 14 days of study entry?
Beschrijving

Hasthepatienthadacutetreatmentforaninfection(otherthanoralthrushorgenitalherpes)orotherseriousmedicalillnesswithin14daysofstudyentry?

Datatype

text

Has the patient had anti-neoplastic treatment for Kaposi's Sarcoma (including chemotherapy, radiation therapy, local therapy, biological therapy, or investigational therapy) within two weeks of study entry?
Beschrijving

Hasthepatienthadanti-neoplastictreatmentforKaposi'sSarcoma(includingchemotherapy,radiationtherapy,localtherapy,biologicaltherapy,orinvestigationaltherapy)withintwoweeksofstudyentry?

Datatype

text

Has the patient had previous local therapy of any KS-indicator lesion within 60 days unless the lesion has clearly progressed since treatment?
Beschrijving

HasthepatienthadpreviouslocaltherapyofanyKS-indicatorlesionwithin60daysunlessthelesionhasclearlyprogressedsincetreatment?

Datatype

text

Has the patient used of investigational drugs other than IND-available anti-retroviral agents?
Beschrijving

HasthepatientusedofinvestigationaldrugsotherthanIND-availableanti-retroviralagents?

Datatype

text

Does the patient have evidence of a prior MI or cardiac ischemia?
Beschrijving

DoesthepatienthaveevidenceofapriorMIorcardiacischemia?

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Eligibility Form for Protocol #040 - PR4001
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Ccrr Module For Eligibility Form For Protocol #040 - Pr4001
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)
ProtocolCoordinatingIdentifierNumber
Item
Study#
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
NCIInstitutionIdentifierCode
Item
Site#
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)
C19202 (NCI Thesaurus ObjectClass)
C1513882 (UMLS 2011AA ObjectClass)
PatientCoordinatingIdentifierNumber
Item
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)
Dateofassessment
Item
Visit Date
text
Item
Does the patient have biopsy proven KS involving the skin, lymph nodes, oral cavity, gastrointestinal (GI) tract and/or lungs?
text
CL.1
Code List
Does the patient have biopsy proven KS involving the skin, lymph nodes, oral cavity, gastrointestinal (GI) tract and/or lungs?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Does the patient have Serologic documentation of HIV infection 21 days prior to study entry, as evidenced by positive ELISA, positive Western Blot, or other federally approved licensed HIV test?
text
CL.2
Code List
Does the patient have Serologic documentation of HIV infection 21 days prior to study entry, as evidenced by positive ELISA, positive Western Blot, or other federally approved licensed HIV test?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is patient's baseline Karnofsky performance status >60%?
text
CL.3
Code List
Is patient's baseline Karnofsky performance status >60%?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is patient's hemoglobin > 8 g/dl within 7 days of study entry?
text
CL.4
Code List
Is patient's hemoglobin > 8 g/dl within 7 days of study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is patient's absolute neutrophil count > 1500 cells/mm3 and platelets > 100,000 cells/mm3 within 7 days of study entry?
text
CL.5
Code List
Is patient's absolute neutrophil count > 1500 cells/mm3 and platelets > 100,000 cells/mm3 within 7 days of study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is patient's creatinine < 1.5 times the upper limit of normal within 7 days of study entry?
text
CL.6
Code List
Is patient's creatinine < 1.5 times the upper limit of normal within 7 days of study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is patient's total bilirubin <1.5x ULN within 7 days of study entry?
text
CL.7
Code List
Is patient's total bilirubin <1.5x ULN within 7 days of study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is patient's AST (SGOT) and ALT (SGPT) < 3 x the upper limit of normal within 7 days of study entry?
text
CL.8
Code List
Is patient's AST (SGOT) and ALT (SGPT) < 3 x the upper limit of normal within 7 days of study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is patient's life expectancy > 3 months?
text
CL.9
Code List
Is patient's life expectancy > 3 months?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Is the patient age of 18 or older?
text
CL.10
Code List
Is the patient age of 18 or older?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Does the patient have ability and willingness to give informed consent?
text
CL.11
Code List
Does the patient have ability and willingness to give informed consent?
CL Item
Yes (Yes)
CL Item
No (No)
Item
If female capable of childbearing, has the patient had a negative serum B-HCG within 72 hours prior to study entry?
text
CL.12
Code List
If female capable of childbearing, has the patient had a negative serum B-HCG within 72 hours prior to study entry?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
N/A (N/A)
Item
If female capable of childbearing, does the patient agree to practice adequate birth control to prevent pregnancy while receiving treatment and for three months after treatment is discontinued?
text
CL.13
Code List
If female capable of childbearing, does the patient agree to practice adequate birth control to prevent pregnancy while receiving treatment and for three months after treatment is discontinued?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
N/A (N/A)
Item
If female, is the patient breast feeding?
text
CL.14
Code List
If female, is the patient breast feeding?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
N/A (N/A)
Item
If male of child fathering potential, does the patient agree to practice adequate birth control?
text
CL.15
Code List
If male of child fathering potential, does the patient agree to practice adequate birth control?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
N/A (N/A)
Item
In the opinion of the investigator, is the patient capable of complying with the protocol?
text
CL.16
Code List
In the opinion of the investigator, is the patient capable of complying with the protocol?
CL Item
Yes (Yes)
CL Item
No (No)
Item
If patient is receiving antiretroviral therapy, is the patient on a stable regimen for at least 4 weeks prior to study entry?
text
CL.17
Code List
If patient is receiving antiretroviral therapy, is the patient on a stable regimen for at least 4 weeks prior to study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Does the patient have concurrent, acute, active opportunistic infection other than oral thrush or genital herpes within 14 days of enrollment?
text
CL.18
Code List
Does the patient have concurrent, acute, active opportunistic infection other than oral thrush or genital herpes within 14 days of enrollment?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Does the patient have symptomatic visceral Kaposi's Sarcoma requiring cytotoxic therapy unless the patient has already been shown to be refractory to or intolerant of all currently approved agents for visceral Kaposi's Sarcoma?
text
CL.19
Code List
Does the patient have symptomatic visceral Kaposi's Sarcoma requiring cytotoxic therapy unless the patient has already been shown to be refractory to or intolerant of all currently approved agents for visceral Kaposi's Sarcoma?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Does the patient have concurrent neoplasia requiring cytotoxic therapy?
text
CL.20
Code List
Does the patient have concurrent neoplasia requiring cytotoxic therapy?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Has the patient had acute treatment for an infection (other than oral thrush or genital herpes) or other serious medical illness within 14 days of study entry?
text
CL.21
Code List
Has the patient had acute treatment for an infection (other than oral thrush or genital herpes) or other serious medical illness within 14 days of study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Has the patient had anti-neoplastic treatment for Kaposi's Sarcoma (including chemotherapy, radiation therapy, local therapy, biological therapy, or investigational therapy) within two weeks of study entry?
text
CL.22
Code List
Has the patient had anti-neoplastic treatment for Kaposi's Sarcoma (including chemotherapy, radiation therapy, local therapy, biological therapy, or investigational therapy) within two weeks of study entry?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Has the patient had previous local therapy of any KS-indicator lesion within 60 days unless the lesion has clearly progressed since treatment?
text
CL.23
Code List
Has the patient had previous local therapy of any KS-indicator lesion within 60 days unless the lesion has clearly progressed since treatment?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Has the patient used of investigational drugs other than IND-available anti-retroviral agents?
text
CL.24
Code List
Has the patient used of investigational drugs other than IND-available anti-retroviral agents?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Does the patient have evidence of a prior MI or cardiac ischemia?
text
CL.25
Code List
Does the patient have evidence of a prior MI or cardiac ischemia?
CL Item
Yes (Yes)
CL Item
No (No)
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