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ID

42956

Description

Enrollment form Demo Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4508911E-AEC4-6A3B-E044-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4508911E-AEC4-6A3B-E044-0003BA3F9857

Mots-clés

Versions (3)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 17/09/2021 17/09/2021 -
Téléchargé le

17 septembre 2021

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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    On-Study - Demo Enrollment - 2725838v1.0

    Anglais

    Dates will appear as 'DD-MON-YYYY'

    1 Formulaires  
    1. StudyEvent: Demo Enrollment
      1. Dates will appear as 'DD-MON-YYYY'
    Demographics
    Description

    Demographics

    Patient Initials Name
    Description

    Patient Initials

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Patient Registration Date
    Description

    PatientRegistrationDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    Patient Gender Category
    Description

    Gender

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS CUI-1
    C0079399
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C17357
    Pregnant or Nursing
    Description

    FemaleBreastFeedingOrPregnancyStatusIndicator

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass-2
    C16576
    UMLS 2011AA ObjectClass-2
    C0086287
    NCI Thesaurus Property
    C37998
    UMLS 2011AA Property
    C1518602
    NCI Thesaurus Property-2
    C25742
    UMLS 2011AA Property-2
    C0032961
    NCI Thesaurus Property-3
    C25688
    UMLS 2011AA Property-3
    C0449438
    NCI Thesaurus Property-4
    C25596
    UMLS 2011AA Property-4
    C0006147
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Patient Birth Date
    Description

    Birth Date

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0421451
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C25155
    Patient/Participant Age
    Description

    PatientAgeValue

    Type de données

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25150
    UMLS 2011AA Property
    C0001779
    Race
    Description

    Racial Group

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS CUI-1
    C0034510
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C17049
    Patient Ethnic Group Category
    Description

    Ethnic Group

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS CUI-1
    C0015031
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C16564
    Disease
    Description

    Disease

    Primary Site of Disease Name
    Description

    PrimarySiteofDiseaseName

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C13717
    UMLS 2011AA ObjectClass
    C1515974
    NCI Thesaurus ObjectClass-2
    C25251
    UMLS 2011AA ObjectClass-2
    C0205225
    NCI Thesaurus Property
    C2991
    UMLS 2011AA Property
    C0012634
    NCI Thesaurus ValueDomain
    C42614
    UMLS 2011AA ValueDomain
    C0027365
    Retour au début de la page

    Similar models

    Dates will appear as 'DD-MON-YYYY'

    1 Formulaires
    1. StudyEvent: Demo Enrollment
      1. Dates will appear as 'DD-MON-YYYY'
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Demographics
    Patient Initials
    Item
    Patient Initials Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    PatientRegistrationDate
    Item
    Patient Registration Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    Item
    Patient Gender Category
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0079399 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C17357 (NCI Thesaurus Property)
    CL.1
    Code List
    Patient Gender Category
    CL Item
    Female (FEMALE)
    C46110 (NCI Thesaurus)
    C0086287 (UMLS 2011AA)
    CL Item
    Male (MALE)
    C46109 (NCI Thesaurus)
    C1706180 (UMLS 2011AA)
    CL Item
    Unknown (UNKNOWN)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    FemaleBreastFeedingOrPregnancyStatusIndicator
    Item
    Pregnant or Nursing
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C16576 (NCI Thesaurus ObjectClass-2)
    C0086287 (UMLS 2011AA ObjectClass-2)
    C37998 (NCI Thesaurus Property)
    C1518602 (UMLS 2011AA Property)
    C25742 (NCI Thesaurus Property-2)
    C0032961 (UMLS 2011AA Property-2)
    C25688 (NCI Thesaurus Property-3)
    C0449438 (UMLS 2011AA Property-3)
    C25596 (NCI Thesaurus Property-4)
    C0006147 (UMLS 2011AA Property-4)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Birth Date
    Item
    Patient Birth Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0421451 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C25155 (NCI Thesaurus Property)
    PatientAgeValue
    Item
    Patient/Participant Age
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25150 (NCI Thesaurus Property)
    C0001779 (UMLS 2011AA Property)
    Item
    Race
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0034510 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C17049 (NCI Thesaurus Property)
    CL.3
    Code List
    Race
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment. (American Indian or Alaska Native)
    C41259 (NCI Thesaurus)
    C1515945 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
    C41260 (NCI Thesaurus)
    C0078988 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)
    C16352 (NCI Thesaurus)
    C0085756 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)
    C41219 (NCI Thesaurus)
    C1513907 (UMLS 2011AA)
    CL Item
    Not Provided Or Available (Not Reported)
    C43234 (NCI Thesaurus)
    C1706613 (UMLS 2011AA)
    CL Item
    Could Not Be Determined Or Unsure (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
    C41261 (NCI Thesaurus)
    C0007457 (UMLS 2011AA)
    Item
    Patient Ethnic Group Category
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0015031 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C16564 (NCI Thesaurus Property)
    CL.4
    Code List
    Patient Ethnic Group Category
    CL Item
    A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (HISPANIC OR LATINO)
    C17459 (NCI Thesaurus)
    C0086409 (UMLS 2011AA)
    CL Item
    A Person Not Meeting The Definition For Hispanic Or Latino. (NOT HISPANIC OR LATINO)
    C41222 (NCI Thesaurus)
    C1518424 (UMLS 2011AA)
    CL Item
    Not Provided Or Available (Not reported)
    C43234 (NCI Thesaurus)
    C1706613 (UMLS 2011AA)
    CL Item
    Could Not Be Determined Or Unsure (UNKNOWN)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item Group
    Disease
    Item
    Primary Site of Disease Name
    text
    C13717 (NCI Thesaurus ObjectClass)
    C1515974 (UMLS 2011AA ObjectClass)
    C25251 (NCI Thesaurus ObjectClass-2)
    C0205225 (UMLS 2011AA ObjectClass-2)
    C2991 (NCI Thesaurus Property)
    C0012634 (UMLS 2011AA Property)
    C42614 (NCI Thesaurus ValueDomain)
    C0027365 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Primary Site of Disease Name
    CL Item
    Bile Duct (Bile Duct)
    C12376 (NCI Thesaurus)
    C0005400 (UMLS 2011AA)
    CL Item
    Breast (Breast)
    C12971 (NCI Thesaurus)
    C0006141 (UMLS 2011AA)
    CL Item
    Cervix (Cervix)
    C12311 (NCI Thesaurus)
    C0007874 (UMLS 2011AA)
    CL Item
    Fallopian Tube (Fallopian Tube)
    C12403 (NCI Thesaurus)
    C0015560 (UMLS 2011AA)
    CL Item
    Lung, Anterior Left Lower Lobe (Lung, Ant-LLL)
    CL Item
    Lung, Anterior Left Upper Lobe (Lung, Ant-LUL)
    CL Item
    Lung, Anterior Right Lower Lobe (Lung, Ant-RLL)
    CL Item
    Lung, Anterior Right Middle Lobe (Lung, Ant-RML)
    CL Item
    Lung, Anterior Right Upper Lobe (Lung, Ant-RUL)
    CL Item
    Lung, Posterior Left Lower Lobe (Lung, Post-LLL)
    CL Item
    Lung, Posterior Left Upper Lobe (Lung, Post-LUL)
    CL Item
    Lung, Posterior Right Lower Lobe (Lung, Post-RLL)
    CL Item
    Lung, Posterior Right Middle Lobe (Lung, Post-RML)
    CL Item
    Lung, Posterior Right Upper Lobe (Lung, Post-RUL)
    CL Item
    Ovary (Ovary)
    C12404 (NCI Thesaurus)
    C0029939 (UMLS 2011AA)
    CL Item
    Prostate (Prostate)
    C12410 (NCI Thesaurus)
    C0033572 (UMLS 2011AA)
    Retour au début de la page 

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