ID

3258

Beschreibung

Concomitant Medication Form A Phase III, Randomized Study of Gemcitabine (Fixed-Dose Rate Infusion) and Oxaliplatin (NSC 266046) Versus Gemcitabine (Fixed-Dose Rate Infusion) Versus Gemcitabine (30-Minute Infusion) in Pancreatic Carcinoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6277C4D-6BBD-3D79-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6277C4D-6BBD-3D79-E034-0003BA0B1A09

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 - Philipp Bruland
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 03.07.15 03.07.15 -
Hochgeladen am

19. September 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00058149 Treatment - Concomitant Medication Form - 2047658v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: Concomitant Medication Form
    1. No Instruction available.
Unnamed1
Beschreibung

Unnamed1

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient?s Name
Beschreibung

Patient'sName

Datentyp

text

ECOG Prot. No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Prot. No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Patient Seq. No.
Beschreibung

ECOGPatientID

Datentyp

text

ECOG Patient Seq. No.
Beschreibung

ECOGPatientID

Datentyp

text

Participating Group Prot. No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Participating Group Patient ID No.
Beschreibung

ParticipatingGroupPatientID

Datentyp

text

Step No.
Beschreibung

StepNo.

Datentyp

text

Group
Beschreibung

ParticipatingGroupName

Datentyp

text

Institution
Beschreibung

InstitutionName

Datentyp

text

Network
Beschreibung

Network

Datentyp

text

Affiliate
Beschreibung

AffiliateName

Datentyp

text

Unnamed2
Beschreibung

Unnamed2

Are data amended? (If yes, please circle amended items in red)
Beschreibung

AmendedDataInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Reporting period Start Date: (M D Y)
Beschreibung

IntervalReportFromDate

Datentyp

date

Reporting period End Date: (M D Y)
Beschreibung

IntervalReportToDate

Datentyp

date

Unnamed3
Beschreibung

Unnamed3

Generic Name (Use brand or trade if generic name unknown)
Beschreibung

AgentName

Datentyp

text

Dose
Beschreibung

Dose

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
Units
Beschreibung

Units

Datentyp

text

other, specify
Beschreibung

other,specify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25179
UMLS 2011AA ObjectClass
C0019993
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
other, specify
Beschreibung

other,specify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25179
UMLS 2011AA ObjectClass
C0019993
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
other, specify
Beschreibung

other,specify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25179
UMLS 2011AA ObjectClass
C0019993
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Frequency
Beschreibung

Frequency

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25515
UMLS 2011AA ObjectClass
C0439603
Route
Beschreibung

AgentAdminRoute

Datentyp

text

Start Date (Leave blank if continuing from a prior report period)
Beschreibung

AgentBeginDate

Datentyp

date

Is this medication continuing?
Beschreibung

Isthismedicationcontinuing?

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Stop Date (Leave blank if continuing)
Beschreibung

AgentEndDate

Datentyp

date

Unnamed4
Beschreibung

Unnamed4

Comments
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beschreibung

InvestigatorSignatureDate

Datentyp

date

Ccrr Module For Concomitant Medication Form
Beschreibung

Ccrr Module For Concomitant Medication Form

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Patient Initials
Beschreibung

PatientInitialsName

Datentyp

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
DCI Name
Beschreibung

DCIName

Datentyp

text

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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: Concomitant Medication Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Prot. No.
text
ECOGProtocolNo.
Item
ECOG Prot. No.
text
ECOGPatientID
Item
ECOG Patient Seq. No.
text
ECOGPatientID
Item
ECOG Patient Seq. No.
text
ParticipatingGroupProtocolNo.
Item
Participating Group Prot. No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID No.
text
StepNo.
Item
Step No.
text
ParticipatingGroupName
Item
Group
text
InstitutionName
Item
Institution
text
Network
Item
Network
text
AffiliateName
Item
Affiliate
text
Item Group
Unnamed2
Item
Are data amended? (If yes, please circle amended items in red)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IntervalReportFromDate
Item
Reporting period Start Date: (M D Y)
date
IntervalReportToDate
Item
Reporting period End Date: (M D Y)
date
Item Group
Unnamed3
AgentName
Item
Generic Name (Use brand or trade if generic name unknown)
text
Dose
Item
Dose
double
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
Item
Units
text
CL.2
Code List
Units
CL Item
capsules (caps) (capsules (caps))
CL Item
gram (gm) (gram (gm))
CL Item
drops (gtts) (drops (gtts))
CL Item
inch (inch) (inch (inch))
CL Item
kilogram (kg) (kilogram (kg))
CL Item
liter (l) (liter (l))
CL Item
microgram (mcg) (microgram (mcg))
CL Item
milliequivalent (mEq) (milliequivalent (mEq))
CL Item
milligram (mg) (milligram (mg))
CL Item
milliliter (ml) (milliliter (ml))
CL Item
ounce (oz) (ounce (oz))
CL Item
tablets (tabs) (tablets (tabs))
CL Item
tablespoon (tbsp) (tablespoon (tbsp))
CL Item
teaspoon (tsp) (teaspoon (tsp))
CL Item
unit (u) (unit (u))
CL Item
other, specify (other, specify)
other,specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
other,specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
other,specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Frequency
text
C25515 (NCI Thesaurus ObjectClass)
C0439603 (UMLS 2011AA ObjectClass)
CL.3
Code List
Frequency
CL Item
Immediately (stat) (immediately (Stat))
CL Item
As Needed (p.r.n) (as needed (P.R.N))
CL Item
Every Day (q.d.) (every day (Q.D.))
CL Item
Every Other Day (q.o.d.) (every other day (Q.O.D.))
CL Item
Twice A Day (b.i.d) (twice a day (B.I.D))
CL Item
Three Times A Day (t.i.d) (three times a day (T.I.D))
CL Item
Four Times A Day (q.i.d) (four times a day (Q.I.D))
CL Item
Twice A Week (b.i.w) (twice a week (B.I.W))
CL Item
Three Times A Week (t.i.w) (three times a week (T.I.W))
CL Item
Before Meals (a.c.) (before meals (A.C.))
CL Item
After Meals (p.c.) (after meals (P.C.))
CL Item
At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep (H.S.))
CL Item
Every 4 Hours (q4hr) (every 4 hours (Q4hr))
CL Item
Every 6 Hours (q6hr) (every 6 hours (Q6hr))
CL Item
Every 8 Hours (q8hr) (every 8 hours (Q8hr))
CL Item
Every 12 Hours (q12hr) (every 12 hours (Q12hr))
CL Item
Other, Specify (other, specify)
Item
Route
text
CL.4
Code List
Route
CL Item
Oral Administration Of Drug (oral (p.o.))
CL Item
subcutaneous (s.c.) (subcutaneous (s.c.))
CL Item
Intramuscular Administration Of Drug (intramuscular (i.m.))
CL Item
Intravenous Administration Of Drug (intravenous (i.v.))
CL Item
rectal (rectal)
CL Item
topical (topical)
CL Item
nasal (nasal)
CL Item
inhaled (inhaled)
CL Item
transdermal (transdermal)
CL Item
sublingual (sublingual)
CL Item
intradermal (intradermal)
CL Item
other, specify (other, specify)
AgentBeginDate
Item
Start Date (Leave blank if continuing from a prior report period)
date
Item
Is this medication continuing?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.5
Code List
Is this medication continuing?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AgentEndDate
Item
Stop Date (Leave blank if continuing)
date
Item Group
Unnamed4
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Concomitant Medication Form
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
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)
DCIName
Item
DCI Name
text
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