ID

42190

Description

AMC-045 Concomitant Medication Form (MED) Cisplatin, Fluorouracil, Cetuximab, and Radiation Therapy in Treating Patients With HIV and Stage I, Stage II, or Stage III Anal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=72844558-61F6-0B0B-E040-BB89AD4314AD

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=72844558-61F6-0B0B-E040-BB89AD4314AD

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 11/28/14 11/28/14 - Martin Dugas
  3. 4/13/21 4/13/21 - Dr. rer. medic Philipp Neuhaus
Uploaded on

April 13, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Anal Cancer NCT00324415 Treatment - AMC-045 Concomitant Medication Form (MED) - 2936871v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-045 Concomitant Medication Form (MED)
    1. No Instruction available.
Ccrr Module For Concomitant Antiretroviral Medications - Rf08
Description

Ccrr Module For Concomitant Antiretroviral Medications - Rf08

Alias
UMLS CUI-1
C2347852
Agent Name
Description

Agent Name

Data type

text

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain
C42614
UMLS CUI-1
C1372955
Dose Level Start Date
Description

AgentDoseLevelBeginDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25488
UMLS 2011AA Property
C0178602
NCI Thesaurus Property
C25554
UMLS 2011AA Property
C0441889
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25431
UMLS 2011AA ValueDomain
C0439659
Total Daily Dose of Agent (or Drug)
Description

DailyAgentTotalDose

Data type

double

Alias
NCI Thesaurus ObjectClass
C25473
UMLS 2011AA ObjectClass
C0332173
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25304
UMLS 2011AA Property
C0439810
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
NCI Thesaurus ValueDomain
C1708
UMLS 2011AA ValueDomain
C0450442
Units
Description

AgentConcomitantAdministrationUOM

Data type

text

Alias
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25730
NCI Thesaurus Property
C25409
NCI Thesaurus ValueDomain
C25709
UMLS CUI-1
C1519795
Other, specify
Description

AgentConcomitantAdministrationSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25730
UMLS 2011AA Property
C0521115
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
Frequency
Description

AgentAdministeredFrequency

Data type

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain
C25515
UMLS 2011AA ValueDomain
C0439603
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Other, specify
Description

AgentAdministeredFrequencySpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ObjectClass
C25409
UMLS 2011AA ObjectClass
C1533734
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Is this an antiretroviral agent
Description

Anti-RetroviralAgentsAdministeredInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus Property
C25382
NCI Metathesaurus ObjectClass
C0599685
UMLS CUI-1
C1512698
UMLS CUI-2
C1521801
Please provide indication (If "no")
Description

Anti-RetroviralAgentsNotAdministeredReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Metathesaurus ObjectClass
C0599685
Is use of this agent ongoing
Description

ConcomitantMedicationAdministrationCurrentInd-3

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C459
NCI Thesaurus ObjectClass
C25730
NCI Thesaurus Property
C25409
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ValueDomain
C25471
UMLS CUI-1
C0013227
UMLS CUI-2
C0521115
UMLS CUI-3
C1533734
UMLS CUI-4
C1512699
UMLS CUI-5
C0521116
Date last taken (If "no" mm/dd/yyyy)
Description

ConcomitantMedicationAdministrationLastDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass
C25730
UMLS 2011AA ObjectClass
C0521115
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25551
UMLS 2011AA ValueDomain
C1517741
Comments
Description

Comments

Alias
UMLS CUI-1
C0947611
Comments
Description

ResearchCommentsText

Data type

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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No Instruction available.

1 forms
  1. StudyEvent: AMC-045 Concomitant Medication Form (MED)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Concomitant Antiretroviral Medications - Rf08
C2347852 (UMLS CUI-1)
Agent
Item
Agent Name
text
C25364 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C1372955 (UMLS CUI-1)
AgentDoseLevelBeginDate
Item
Dose Level Start Date
date
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25488 (NCI Thesaurus Property)
C0178602 (UMLS 2011AA Property)
C25554 (NCI Thesaurus Property)
C0441889 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
DailyAgentTotalDose
Item
Total Daily Dose of Agent (or Drug)
double
C25473 (NCI Thesaurus ObjectClass)
C0332173 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ValueDomain)
C0450442 (UMLS 2011AA ValueDomain)
Item
Units
text
C1708 (NCI Thesaurus ObjectClass)
C25730 (NCI Thesaurus Property)
C25409 (NCI Thesaurus Property)
C25709 (NCI Thesaurus ValueDomain)
C1519795 (UMLS CUI-1)
CL.1
Code List
Units
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Milligram (mg)
CL Item
Microgram (µg)
CL Item
Milliliter (ml)
CL Item
Unit (U)
CL Item
International Unit (IU)
CL Item
Capsules (Caps)
CL Item
Tablets (Tabl)
CL Item
Drops (Dr)
AgentConcomitantAdministrationSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus Property)
C0521115 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
Item
Frequency
text
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25515 (NCI Thesaurus ValueDomain)
C0439603 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.2
Code List
Frequency
CL Item
Once A Day (q.d.) (Once a day (Q.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
>4x/day (>4X/day)
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
At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep (H.S.))
CL Item
Every Other Day (q.o.d.) (every other day (Q.O.D.))
CL Item
Weekly (Weekly)
CL158132 (NCI Metathesaurus)
CL Item
Monthly (Monthly)
CL Item
As Needed (p.r.n) (as needed (P.R.N))
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AgentAdministeredFrequencySpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus ObjectClass)
C1533734 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Anti-RetroviralAgentsAdministeredInd-2
Item
Is this an antiretroviral agent
boolean
C38147 (NCI Thesaurus ValueDomain)
C25382 (NCI Thesaurus Property)
C0599685 (NCI Metathesaurus ObjectClass)
C1512698 (UMLS CUI-1)
C1521801 (UMLS CUI-2)
Anti-RetroviralAgentsNotAdministeredReason
Item
Please provide indication (If "no")
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0599685 (NCI Metathesaurus ObjectClass)
ConcomitantMedicationAdministrationCurrentInd-3
Item
Is use of this agent ongoing
boolean
C459 (NCI Thesaurus ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C25409 (NCI Thesaurus Property)
C38148 (NCI Thesaurus ValueDomain)
C25471 (NCI Thesaurus ValueDomain)
C0013227 (UMLS CUI-1)
C0521115 (UMLS CUI-2)
C1533734 (UMLS CUI-3)
C1512699 (UMLS CUI-4)
C0521116 (UMLS CUI-5)
ConcomitantMedicationAdministrationLastDate
Item
Date last taken (If "no" mm/dd/yyyy)
date
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain)
C1517741 (UMLS 2011AA ValueDomain)
Item Group
Comments
C0947611 (UMLS CUI-1)
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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