ID

43128

Beschreibung

Enrollment form for C3D 3.12 Adopters Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=790C39AF-C663-A8ED-E040-BB89AD435AB1

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=790C39AF-C663-A8ED-E040-BB89AD435AB1

Stichworte

Klinische Studie [Dokumenttyp]

Registration

Hochgeladen am

20. September 2021

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy

Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren

Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

On-Study - ENROLLMENT - 2393048v1.2

Modell
Details

Dates will appear as 'DD-MON-YYYY'

1 Formulare

StudyEvent: ENROLLMENT
1. Dates will appear as 'DD-MON-YYYY'

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

DEMOGRAPHY

Item Group

Demographics

PersonGenderTextType

Item

Gender of a Person

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS 2011AA Property)

CL.1

Code List

Gender of a Person

CL Item

Female Gender (Female Gender)

C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)

CL Item

Male Gender (Male Gender)

C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Unspecified (Unspecified)

C38046 (NCI Thesaurus)
C0205370 (UMLS 2011AA)

PersonBirthDate

Item

Patient's Date of Birth

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA 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)

RaceCategoryText

Item

Race

text

C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C17049 (NCI Thesaurus ObjectClass)
C0034510 (UMLS 2011AA ObjectClass)

CL.2

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)

EthnicGroupCategoryText

Item

Ethnicity

text

C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16564 (NCI Thesaurus ObjectClass)
C0015031 (UMLS 2011AA ObjectClass)

CL.3

Code List

Ethnicity

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)

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)

PrestudyLabDate

Item

Prestudy Lab Date

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38470 (NCI Thesaurus ObjectClass)
C0039593 (NCI Metathesaurus Property)

PatientIdentifier

Item

Patient Identifier

text

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)

GEOGRAPHY AND GROUP

Item Group

Registration

PatientSubgroupAssignment

Item

Patient Subgroup Assignment

text

C0030705 (NCI Metathesaurus ObjectClass)
C25693 (NCI Thesaurus Property)
C1515021 (UMLS 2011AA Property)

RegisteringGroup

Item

Registering Group

text

C25646 (NCI Thesaurus ObjectClass)
C1514821 (UMLS 2011AA ObjectClass)
C43359 (NCI Thesaurus Property)
C0441833 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)

RegisteringInstitutionIdentificationCode

Item

Registering Institution Identification Code

text

C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25645 (NCI Thesaurus ObjectClass)
CL281747 (NCI Metathesaurus Property)

CountryCode

Item

Country Code

text

C25162 (NCI Thesaurus Property)
C0805701 (UMLS 2011AA Property)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25464 (NCI Thesaurus ObjectClass)
C0454664 (UMLS 2011AA ObjectClass)

CL.4

Code List

Country Code

CL Item

Ascension Island (AC)

CL Item

Andorra (AD)

C16289 (NCI Thesaurus)
C0002838 (UMLS 2011AA)

CL Item

United Arab Emirates (AE)

C17232 (NCI Thesaurus)
C0041698 (UMLS 2011AA)

CL Item

Afghanistan (AF)

C16267 (NCI Thesaurus)
C0001732 (UMLS 2011AA)

CL Item

Antigua And Barbuda (AG)

C16303 (NCI Thesaurus)
C0003354 (UMLS 2011AA)

CL Item

Anguilla (AI)

C20133 (NCI Thesaurus)
C0003353 (UMLS 2011AA)

CL Item

Albania (AL)

CL Item

Armenia (AM)

C16306 (NCI Thesaurus)
C0003798 (UMLS 2011AA)

CL Item

Netherland Antilles (AN)

CL Item

Angola (AO)

C16292 (NCI Thesaurus)
C0003023 (UMLS 2011AA)

CL Item

Antarctica (AQ)

C18007 (NCI Thesaurus)
C0454691 (UMLS 2011AA)

CL Item

Argentina (AR)

C16305 (NCI Thesaurus)
C0003761 (UMLS 2011AA)

CL Item

American Samoa (AS)

C17739 (NCI Thesaurus)
C0242536 (UMLS 2011AA)

CL Item

Austria (AT)

C16312 (NCI Thesaurus)
C0004348 (UMLS 2011AA)

CL Item

Australia (AU)

C16311 (NCI Thesaurus)
C0004340 (UMLS 2011AA)

CL Item

Aruba (AW)

C17884 (NCI Thesaurus)
C0282379 (UMLS 2011AA)

CL Item

Azerbaidjan (AZ)

CL Item

Bosnia-herzegovina (BA)

C16361 (NCI Thesaurus)
C0006036 (UMLS 2011AA)

CL Item

Barbados (BB)

C16324 (NCI Thesaurus)
C0004739 (UMLS 2011AA)

CL Item

Bangladesh (BD)

C16323 (NCI Thesaurus)
C0004732 (UMLS 2011AA)

CL Item

Belgium (BE)

C16329 (NCI Thesaurus)
C0004950 (UMLS 2011AA)

CL Item

Burkina Faso (BF)

C16369 (NCI Thesaurus)
C0006409 (UMLS 2011AA)

CL Item

Bulgaria (BG)

C16368 (NCI Thesaurus)
C0006368 (UMLS 2011AA)

CL Item

Bahrain (BH)

C16322 (NCI Thesaurus)
C0004684 (UMLS 2011AA)

CL Item

Burundi (BI)

C16371 (NCI Thesaurus)
C0006448 (UMLS 2011AA)

CL Item

Benin (BJ)

CL Item

Bermuda (BM)

C16334 (NCI Thesaurus)
C0005126 (UMLS 2011AA)

CL Item

Brunei Darussalam (BN)

C16367 (NCI Thesaurus)
C0006320 (UMLS 2011AA)

CL Item

Bolivia (BO)

C16359 (NCI Thesaurus)
C0005918 (UMLS 2011AA)

CL Item

Brazil (BR)

C16364 (NCI Thesaurus)
C0006137 (UMLS 2011AA)

CL Item

Bahamas (BS)

C16321 (NCI Thesaurus)
C0004683 (UMLS 2011AA)

CL Item

Bhutan (BT)

C16336 (NCI Thesaurus)
C0005341 (UMLS 2011AA)

CL Item

Bouvet Island (BV)

C20104 (NCI Thesaurus)
C1511278 (UMLS 2011AA)

CL Item

Botswana (BW)

C16363 (NCI Thesaurus)
C0006041 (UMLS 2011AA)

CL Item

Belarus (BY)

C16372 (NCI Thesaurus)
C0006539 (UMLS 2011AA)

CL Item

Belize (BZ)

C16331 (NCI Thesaurus)
C0004952 (UMLS 2011AA)

CL Item

Canada (CA)

C16380 (NCI Thesaurus)
C0006823 (UMLS 2011AA)

CL Item

Cocos Isl. (CC)

CL Item

Rep. Dem. Congo (CD)

CL Item

Central African Rep. (CF)

CL Item

Congo (CG)

C16467 (NCI Thesaurus)
C0009738 (UMLS 2011AA)

CL Item

Switzerland (CH)

C17181 (NCI Thesaurus)
C0039021 (UMLS 2011AA)

CL Item

Ivory Coast (CI)

CL Item

Cook Islands (CK)

C16469 (NCI Thesaurus)
C0009956 (UMLS 2011AA)

CL Item

Chile (CL)

CL Item

Cameroon (CM)

C16379 (NCI Thesaurus)
C0006802 (UMLS 2011AA)

CL Item

China (CN)

C16428 (NCI Thesaurus)
C0008115 (UMLS 2011AA)

CL Item

Colombia (CO)

C16449 (NCI Thesaurus)
C3245499 (UMLS 2011AA)

CL Item

Costa Rica (CR)

C16470 (NCI Thesaurus)
C0010182 (UMLS 2011AA)

CL Item

Cuba (CU)

C16477 (NCI Thesaurus)
C0010435 (UMLS 2011AA)

CL Item

Cape Verde (CV)

C16382 (NCI Thesaurus)
C0006893 (UMLS 2011AA)

CL Item

Christmas Island (CX)

C44482 (NCI Thesaurus)
C0006888 (UMLS 2011AA)

CL Item

Cyprus (CY)

C16480 (NCI Thesaurus)
C0010622 (UMLS 2011AA)

CL Item

Czech Republic (CZ)

C17668 (NCI Thesaurus)
C0206578 (UMLS 2011AA)

CL Item

Germany (DE)

CL Item

Djibouti (DJ)

CL Item

Denmark (DK)

CL Item

Dominica (DM)

CL Item

Dominican Republic (DO)

CL Item

Algeria (DZ)

CL Item

Ecuador (EC)

CL Item

Estonia (EE)

CL Item

Egypt (EG)

CL Item

Western Sahara (EH)

CL Item

Eritrea (ER)

CL Item

Spain (ES)

CL Item

Ethiopia (ET)

CL Item

Finland (FI)

CL Item

Fiji (FJ)

CL Item

Falkland Isl. (FK)

CL Item

Micronesia (FM)

CL Item

Faroe Islands (FO)

CL Item

France (FR)

CL Item

France (european Ter.) (FX)

CL Item

Gabon (GA)

CL Item

Great Britain (GB)

CL Item

Grenada (GD)

CL Item

Georgia (GE)

CL Item

Guiana (fr.) (GF)

CL Item

Guernsey (GG)

CL Item

Ghana (GH)

CL Item

Gibraltar (GI)

CL Item

Greenland (GL)

CL Item

Gambia (GM)

CL Item

Guinea (GN)

CL Item

Guadeloupe (fr.) (GP)

CL Item

Equatorial Guinea (GQ)

CL Item

Greece (GR)

CL Item

South Georgia And South Sandwich Islands (GS)

CL Item

Guatemala (GT)

CL Item

Guam (us) (GU)

CL Item

Guinea Bissau (GW)

CL Item

Guyana (GY)

CL Item

Hong Kong (HK)

CL Item

Heard & Mcdonald Isl. (HM)

CL Item

Honduras (HN)

C16694 (NCI Thesaurus)
C0019905 (UMLS 2011AA)

CL Item

Croatia (HR)

C16474 (NCI Thesaurus)
C0010343 (UMLS 2011AA)

CL Item

Haiti (HT)

C16660 (NCI Thesaurus)
C0018510 (UMLS 2011AA)

CL Item

Hungary (HU)

C16699 (NCI Thesaurus)
C0020174 (UMLS 2011AA)

CL Item

Indonesia (ID)

C16728 (NCI Thesaurus)
C0021247 (UMLS 2011AA)

CL Item

Ireland (IE)

C16757 (NCI Thesaurus)
C0022067 (UMLS 2011AA)

CL Item

Israel (IL)

C16760 (NCI Thesaurus)
C0022271 (UMLS 2011AA)

CL Item

Isle Of Man (IM)

C0022132 (NCI Metathesaurus)

CL Item

India (IN)

C16727 (NCI Thesaurus)
C0021201 (UMLS 2011AA)

CL Item

British Indian O. Ter. (IO)

CL Item

Iraq (IQ)

C16756 (NCI Thesaurus)
C0022066 (UMLS 2011AA)

CL Item

Iran (IR)

C16755 (NCI Thesaurus)
C0022065 (UMLS 2011AA)

CL Item

Iceland (IS)

C16704 (NCI Thesaurus)
C0020750 (UMLS 2011AA)

CL Item

Italy (IT)

C16761 (NCI Thesaurus)
C0022277 (UMLS 2011AA)

CL Item

Jersey (JE)

CL Item

Jamaica (JM)

C16763 (NCI Thesaurus)
C0022337 (UMLS 2011AA)

CL Item

Jordan (JO)

C16765 (NCI Thesaurus)
C0022418 (UMLS 2011AA)

CL Item

Japan (JP)

C16764 (NCI Thesaurus)
C0022341 (UMLS 2011AA)

CL Item

Kenya (KE)

C16769 (NCI Thesaurus)
C0022558 (UMLS 2011AA)

CL Item

Kyrgyz Republic (KG)

CL Item

Cambodia (KH)

C16378 (NCI Thesaurus)
C0006797 (UMLS 2011AA)

CL Item

Kiribati (KI)

C16639 (NCI Thesaurus)
C0017550 (UMLS 2011AA)

CL Item

Comoros (KM)

C16458 (NCI Thesaurus)
C0009490 (UMLS 2011AA)

CL Item

St. Kitts Nevis Anguilla (KN)

CL Item

Korea (north) (KP)

CL Item

Korea (south) (KR)

CL Item

Kuwait (KW)

C16775 (NCI Thesaurus)
C0022804 (UMLS 2011AA)

CL Item

Cayman Islands (KY)

C16391 (NCI Thesaurus)
C0007481 (UMLS 2011AA)

CL Item

Kazakstan (KZ)

CL Item

Laos (LA)

CL Item

Lebanon (LB)

C16784 (NCI Thesaurus)
C0023190 (UMLS 2011AA)

CL Item

Saint Lucia (LC)

C17113 (NCI Thesaurus)
C0036056 (UMLS 2011AA)

CL Item

Liechtenstein (LI)

C16794 (NCI Thesaurus)
C0023668 (UMLS 2011AA)

CL Item

Sri Lanka (LK)

C17163 (NCI Thesaurus)
C0038088 (UMLS 2011AA)

CL Item

Liberia (LR)

C16791 (NCI Thesaurus)
C0023617 (UMLS 2011AA)

CL Item

Lesotho (LS)

CL Item

Lithuania (LT)

C16799 (NCI Thesaurus)
C0023879 (UMLS 2011AA)

CL Item

Luxembourg (LU)

C16803 (NCI Thesaurus)
C0024176 (UMLS 2011AA)

CL Item

Latvia (LV)

C16783 (NCI Thesaurus)
C0023128 (UMLS 2011AA)

CL Item

Libya (LY)

CL Item

Morocco (MA)

C16878 (NCI Thesaurus)
C0026544 (UMLS 2011AA)

CL Item

Monaco (MC)

C16874 (NCI Thesaurus)
C0026405 (UMLS 2011AA)

CL Item

Moldova (MD)

C16871 (NCI Thesaurus)
C0026374 (UMLS 2011AA)

CL Item

Madagascar (MG)

C16808 (NCI Thesaurus)
C0024443 (UMLS 2011AA)

CL Item

Marshall Islands (MH)

C16822 (NCI Thesaurus)
C0024851 (UMLS 2011AA)

CL Item

Macedonia (MK)

C0700290 (NCI Metathesaurus)

CL Item

Mali (ML)

C16816 (NCI Thesaurus)
C0024581 (UMLS 2011AA)

CL Item

Myanmar (MM)

C16370 (NCI Thesaurus)
C0006416 (UMLS 2011AA)

CL Item

Mongolia (MN)

C16875 (NCI Thesaurus)
C0026410 (UMLS 2011AA)

CL Item

Macau (MO)

C16807 (NCI Thesaurus)
C0024403 (UMLS 2011AA)

CL Item

Northern Mariana Isl. (MP)

CL Item

Martinique (fr.) (MQ)

CL Item

Mauritania (MR)

C16826 (NCI Thesaurus)
C0024943 (UMLS 2011AA)

CL Item

Montserrat (MS)

C16876 (NCI Thesaurus)
C0026514 (UMLS 2011AA)

CL Item

Malta (MT)

C16817 (NCI Thesaurus)
C0024653 (UMLS 2011AA)

CL Item

Mauritius (MU)

C16827 (NCI Thesaurus)
C0024944 (UMLS 2011AA)

CL Item

Maldives (MV)

C16815 (NCI Thesaurus)
C0024553 (UMLS 2011AA)

CL Item

Malawi (MW)

C16813 (NCI Thesaurus)
C0024548 (UMLS 2011AA)

CL Item

Mexico (MX)

C16850 (NCI Thesaurus)
C0025885 (UMLS 2011AA)

CL Item

Malaysia (MY)

C16814 (NCI Thesaurus)
C0024552 (UMLS 2011AA)

CL Item

Mozambique (MZ)

C16882 (NCI Thesaurus)
C0026655 (UMLS 2011AA)

CL Item

Namibia (NA)

C16891 (NCI Thesaurus)
C0027366 (UMLS 2011AA)

CL Item

New Caledonia (fr.) (NC)

CL Item

Niger (NE)

C16916 (NCI Thesaurus)
C0028074 (UMLS 2011AA)

CL Item

Norfolk Island (NF)

C16919 (NCI Thesaurus)
C0028366 (UMLS 2011AA)

CL Item

Nigeria (NG)

C16917 (NCI Thesaurus)
C0028075 (UMLS 2011AA)

CL Item

Nicaragua (NI)

C16915 (NCI Thesaurus)
C0028002 (UMLS 2011AA)

CL Item

Netherlands (NL)

C16903 (NCI Thesaurus)
C0027778 (UMLS 2011AA)

CL Item

Norway (NO)

C16920 (NCI Thesaurus)
C0028423 (UMLS 2011AA)

CL Item

Nepal (NP)

C16901 (NCI Thesaurus)
C0027689 (UMLS 2011AA)

CL Item

Nauru (NR)

C16896 (NCI Thesaurus)
C0027496 (UMLS 2011AA)

CL Item

Niue (NU)

C16918 (NCI Thesaurus)
C0028219 (UMLS 2011AA)

CL Item

New Zealand (NZ)

C16914 (NCI Thesaurus)
C0027978 (UMLS 2011AA)

CL Item

Oman (OM)

C16933 (NCI Thesaurus)
C0028971 (UMLS 2011AA)

CL Item

Other (Other)

CL Item

Panama (PA)

C16951 (NCI Thesaurus)
C0030266 (UMLS 2011AA)

CL Item

Peru (PE)

C16972 (NCI Thesaurus)
C0031238 (UMLS 2011AA)

CL Item

Polynesia (fr.) (PF)

CL Item

Papua New Guinea (PG)

C16952 (NCI Thesaurus)
C0030375 (UMLS 2011AA)

CL Item

Philippines (PH)

CL Item

Pakistan (PK)

C16949 (NCI Thesaurus)
C0030211 (UMLS 2011AA)

CL Item

Poland (PL)

C17002 (NCI Thesaurus)
C0032356 (UMLS 2011AA)

CL Item

St. Pierre & Miquelon (PM)

CL Item

Pitcairn (PN)

C16993 (NCI Thesaurus)
C0031995 (UMLS 2011AA)

CL Item

Puerto Rico (PR)

C17043 (NCI Thesaurus)
C0034044 (UMLS 2011AA)

CL Item

Portugal (PT)

C17006 (NCI Thesaurus)
C0032729 (UMLS 2011AA)

CL Item

Palau (PW)

C17733 (NCI Thesaurus)
C0242397 (UMLS 2011AA)

CL Item

Paraguay (PY)

C16953 (NCI Thesaurus)
C0030428 (UMLS 2011AA)

CL Item

Qatar (QA)

C17045 (NCI Thesaurus)
C0034366 (UMLS 2011AA)

CL Item

Reunion (fr.) (RE)

CL Item

Romania (RO)

C17108 (NCI Thesaurus)
C0035826 (UMLS 2011AA)

CL Item

Russian Federation (RU)

CL Item

Rwanda (RW)

C17112 (NCI Thesaurus)
C0035978 (UMLS 2011AA)

CL Item

Saudi Arabia (SA)

C17117 (NCI Thesaurus)
C0036243 (UMLS 2011AA)

CL Item

Solomon Islands (SB)

C17148 (NCI Thesaurus)
C0037623 (UMLS 2011AA)

CL Item

Seychelles (SC)

C17129 (NCI Thesaurus)
C0036919 (UMLS 2011AA)

CL Item

Sudan (SD)

C17170 (NCI Thesaurus)
C0038642 (UMLS 2011AA)

CL Item

Sweden (SE)

C17180 (NCI Thesaurus)
C0038995 (UMLS 2011AA)

CL Item

Singapore (SG)

C17134 (NCI Thesaurus)
C0037173 (UMLS 2011AA)

CL Item

St. Helena (SH)

CL Item

Slovenia (SI)

C17138 (NCI Thesaurus)
C0037334 (UMLS 2011AA)

CL Item

Svalbard & Jan Mayen Isl. (SJ)

CL Item

Slovakia (SK)

C17669 (NCI Thesaurus)
C0206579 (UMLS 2011AA)

CL Item

Sierra Leone (SL)

C17130 (NCI Thesaurus)
C0037063 (UMLS 2011AA)

CL Item

San Marino (SM)

C17115 (NCI Thesaurus)
C0036154 (UMLS 2011AA)

CL Item

Senegal (SN)

C17121 (NCI Thesaurus)
C0036644 (UMLS 2011AA)

CL Item

Somalia (SO)

C17149 (NCI Thesaurus)
C0037640 (UMLS 2011AA)

CL Item

Suriname (SR)

C17175 (NCI Thesaurus)
C0038944 (UMLS 2011AA)

CL Item

St. Tome And Principe (ST)

CL Item

Soviet Union (SU)

CL Item

El Salvador (SV)

C16532 (NCI Thesaurus)
C0013754 (UMLS 2011AA)

CL Item

Syria (SY)

C17182 (NCI Thesaurus)
C0039138 (UMLS 2011AA)

CL Item

Swaziland (SZ)

C17179 (NCI Thesaurus)
C0038983 (UMLS 2011AA)

CL Item

Turks & Caicos Islands (TC)

CL Item

Chad (TD)

C16412 (NCI Thesaurus)
C0007928 (UMLS 2011AA)

CL Item

French Southern Terr. (TF)

CL Item

Togo (TG)

C17202 (NCI Thesaurus)
C0040363 (UMLS 2011AA)

CL Item

Thailand (TH)

C17192 (NCI Thesaurus)
C0039725 (UMLS 2011AA)

CL Item

Tadjikistan (TJ)

CL Item

Tokelau (TK)

C17704 (NCI Thesaurus)
C0220928 (UMLS 2011AA)

CL Item

Turkmenistan (TM)

C17223 (NCI Thesaurus)
C0041403 (UMLS 2011AA)

CL Item

Tunisia (TN)

C17221 (NCI Thesaurus)
C0041388 (UMLS 2011AA)

CL Item

Tonga (TO)

CL Item

East Timor (TP)

C17200 (NCI Thesaurus)
C1452561 (UMLS 2011AA)

CL Item

Turkey (TR)

C17222 (NCI Thesaurus)
C0041400 (UMLS 2011AA)

CL Item

Trinidad & Tobago (TT)

CL Item

Tuvalu (TV)

C17225 (NCI Thesaurus)
C0041413 (UMLS 2011AA)

CL Item

Taiwan (TW)

C17184 (NCI Thesaurus)
C0039260 (UMLS 2011AA)

CL Item

Tanzania (TZ)

C17185 (NCI Thesaurus)
C0039298 (UMLS 2011AA)

CL Item

Ukraine (UA)

C17229 (NCI Thesaurus)
C0041580 (UMLS 2011AA)

CL Item

Uganda (UG)

C17228 (NCI Thesaurus)
C0041573 (UMLS 2011AA)

CL Item

United Kingdom (UK)

C17233 (NCI Thesaurus)
C0041700 (UMLS 2011AA)

CL Item

Us Minor Outlying Isl. (UM)

CL Item

Usa (US)

CL Item

Uruguay (UY)

C17244 (NCI Thesaurus)
C0042113 (UMLS 2011AA)

CL Item

Uzbekistan (UZ)

C17246 (NCI Thesaurus)
C0042177 (UMLS 2011AA)

CL Item

Vatican City State (VA)

CL Item

St. Vincent & Grenadines (VC)

CL Item

Venezuela (VE)

C17250 (NCI Thesaurus)
C0042469 (UMLS 2011AA)

CL Item

Virgin Islands (brit) (VG)

CL Item

Virgin Islands (us) (VI)

CL Item

Vietnam (VN)

C17252 (NCI Thesaurus)
C0042658 (UMLS 2011AA)

CL Item

Vanuatu (VU)

C17247 (NCI Thesaurus)
C0042321 (UMLS 2011AA)

CL Item

Wallis & Futuna Islands (WF)

CL Item

Western Samoa (WS)

CL Item

Yemen (YE)

C17264 (NCI Thesaurus)
C0043402 (UMLS 2011AA)

CL Item

Mayotte (YT)

C16828 (NCI Thesaurus)
C0024974 (UMLS 2011AA)

CL Item

Yugoslavia (YU)

CL Item

South Africa (ZA)

CL Item

Zambia (ZM)

C17267 (NCI Thesaurus)
C0043445 (UMLS 2011AA)

CL Item

Dem. Rep. Of Congo (ZR)

CL Item

Zimbabwe (ZW)

C17268 (NCI Thesaurus)
C0043476 (UMLS 2011AA)

AddressPostalCodeIdentifier

Item

ZIP Code

text

C25407 (NCI Thesaurus ObjectClass)
C1442065 (UMLS 2011AA ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
C25407 (NCI Thesaurus ValueDomain-2)
C1442065 (UMLS 2011AA ValueDomain-2)
C25621 (NCI Thesaurus ValueDomain-3)
C1514254 (UMLS 2011AA ValueDomain-3)

PaymentMethod

Item

Payment Method

text

C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25371 (NCI Thesaurus ObjectClass)
C0680264 (UMLS 2011AA ObjectClass)

CL.5

Code List

Payment Method

CL Item

Private Insurance (1)

CL Item

Medicare (2)

C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)

CL Item

Medicare And Private Insurance (3)

CL Item

Medicaid (4)

C0025071 (NCI Metathesaurus)

CL Item

Medicaid And Medicare (5)

CL Item

Military Or Veterans Sponsored Nos (6)

CL Item

Military Sponsored (including Champus &tricare) (6a)

CL Item

Veterans Sponsored (6b)

CL Item

Self Pay (no Insurance) (7)

CL Item

No Means Of Payment (no Insurance) (8)

CL Item

Other (98)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

Unknown (99)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

HISTORY

Item Group

Disease

PrimarySiteofDiseaseName

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.6

Code List

Primary Site of Disease Name

CL Item

Adrenal Gland (Adrenal Gland)

C12666 (NCI Thesaurus)
C0001625 (UMLS 2011AA)

CL Item

Anus (Anus)

C43362 (NCI Thesaurus)
C0003461 (UMLS 2011AA)

CL Item

Appendix (Appendix)

C12380 (NCI Thesaurus)
C0003617 (UMLS 2011AA)

CL Item

Back (Back)

C13062 (NCI Thesaurus)
C0205095 (UMLS 2011AA)

CL Item

Bile Duct (Bile Duct)

C12376 (NCI Thesaurus)
C0005400 (UMLS 2011AA)

CL Item

Bladder (Bladder)

C12414 (NCI Thesaurus)
C0005682 (UMLS 2011AA)

CL Item

Bone Marrow (Bone Marrow)

C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)

CL Item

Brainstem (Brainstem)

CL Item

Breast (Breast)

C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)

CL Item

Cerebellum (Cerebellum)

C12445 (NCI Thesaurus)
C0007765 (UMLS 2011AA)

CL Item

Cerebrum (Cerebrum)

CL Item

Cervix (Cervix)

C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)

CL Item

Chest (Chest)

C25389 (NCI Thesaurus)
C0817096 (UMLS 2011AA)

CL Item

Colon (Colon)

C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)

CL Item

Cerebrospinal Fluid (CSF)

C12692 (NCI Thesaurus)
C0007806 (UMLS 2011AA)

CL Item

Duodenum (Duodenum)

C12263 (NCI Thesaurus)
C0013303 (UMLS 2011AA)

CL Item

Ear, External (Ear, External)

CL Item

Ear, Inner (Ear, Inner)

CL Item

Ear, Mid (Ear, Mid)

CL Item

Esophagus (Esophagus)

C12389 (NCI Thesaurus)
C0014876 (UMLS 2011AA)

CL Item

Eye, Globe (Eye, Globe)

CL Item

Eye, Orbit (Eye, Orbit)

CL Item

Fallopian Tube (Fallopian Tube)

C12403 (NCI Thesaurus)
C0015560 (UMLS 2011AA)

CL Item

Feet (Feet)

CL Item

Femur (Femur)

C12717 (NCI Thesaurus)
C0015811 (UMLS 2011AA)

CL Item

Fibula (Fibula)

C12718 (NCI Thesaurus)
C0016068 (UMLS 2011AA)

CL Item

Hands (Hands)

CL Item

Hilum, Thoracic (Hilum)

CL Item

Humerus (Humerus)

C12731 (NCI Thesaurus)
C0020164 (UMLS 2011AA)

CL Item

Ileum (Ileum)

CL Item

Iliac Bone (Iliac)

CL Item

Jejunum (Jejunum)

C12388 (NCI Thesaurus)
C0022378 (UMLS 2011AA)

CL Item

Kidney (Kidney)

C12415 (NCI Thesaurus)
C0022646 (UMLS 2011AA)

CL Item

Liver (Liver)

C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)

CL Item

Lymph Node (LN)

C12745 (NCI Thesaurus)
C0024204 (UMLS 2011AA)

CL Item

Lymph Node, Axilla (LN, Axilla)

CL Item

Lymph Node, Brachial (LN, Brachial)

CL Item

Lymph Node, Cervical (LN, Cervical)

CL Item

Lymph Node, Epitrochlear (LN, Epitrochlear)

CL Item

Lymph Node, Femoral (LN, Femoral)

CL Item

Lymph Node, Hilar (LN, Hilar)

CL Item

Lymph Node, Iliac (LN, Iliac)

CL Item

Lymph Node, Inguinal (LN, Inguinal)

CL Item

Lymph Node, Internal Mammary (LN, Internal Mammary)

CL Item

Lymph Node, Mediastinal (LN, Mediastinal)

CL Item

Lymph Node, Mesenteric (LN, Mesenteric)

CL Item

Lymph Node, Mid-pelvis (LN, Mid Pelvis)

CL Item

Lymph Node, Neck (LN, Neck)

CL Item

Lymph Node, Occipital (LN, Occipital)

CL Item

Lymph Node, Paraaortic (LN, Paraaortic)

CL Item

Lymph Node, Pelvis (LN, Pelvis)

CL Item

Lymph Node, Periauricular (LN, Periauricular)

CL Item

Lymph Node, Popliteal (LN, Popliteal)

CL Item

Lymph Node, Retroperitoneal (LN, Retroperitoneal)

CL Item

Lymph Node(s), Subclavian (LN, Subclavian)

CL Item

Lymph Node, Submental (LN, Submental)

CL Item

Lymph Node, Supraclavicular (LN, Supraclavicular)

CL Item

Lung (Lung)

C12468 (NCI Thesaurus)
C0024109 (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

Mandible (Mandible)

C12290 (NCI Thesaurus)
C0024687 (UMLS 2011AA)

CL Item

Mediastinum (Mediastinum)

C12748 (NCI Thesaurus)
C0025066 (UMLS 2011AA)

CL Item

Mouth (Mouth)

C0922752 (NCI Metathesaurus)

CL Item

Muscle, Lower Extremity Distal (Muscle, LE DIstal)

CL Item

Muscle, Lower Extremity Proximal (Muscle, LE Proximal)

CL Item

Muscle, Upper Extremity Distal (Muscle, UE Distal)

CL Item

Muscle, Upper Extremity Proximal (Muscle, UE Proximal)

CL Item

Nasopharynx (Nasopharynx)

C12423 (NCI Thesaurus)
C0027442 (UMLS 2011AA)

CL Item

Nose (Nose)

CL Item

Other Site (Other Site)

CL Item

Ovary (Ovary)

C12404 (NCI Thesaurus)
C0029939 (UMLS 2011AA)

CL Item

Pancreas (Pancreas)

C12393 (NCI Thesaurus)
C0030274 (UMLS 2011AA)

CL Item

Pelvis (Pelvis)

C12767 (NCI Thesaurus)
C0030797 (UMLS 2011AA)

CL Item

Penis (Penis)

C12409 (NCI Thesaurus)
C0030851 (UMLS 2011AA)

CL Item

Pericardium (Pericardium)

C13005 (NCI Thesaurus)
C0031050 (UMLS 2011AA)

CL Item

Peripheral Blood (Peripheral Blood)

C0229664 (NCI Metathesaurus)

CL Item

Pharynx (Pharynx)

C12425 (NCI Thesaurus)
C0031354 (UMLS 2011AA)

CL Item

Pleura (Pleura)

C12469 (NCI Thesaurus)
C0032225 (UMLS 2011AA)

CL Item

Prostate (Prostate)

C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)

CL Item

Radius (Radius)

C63921 (NCI Thesaurus)
C1306504 (UMLS 2011AA)

CL Item

Rectum (Rectum)

C12390 (NCI Thesaurus)
C0034896 (UMLS 2011AA)

CL Item

Ribs (Ribs)

C12782 (NCI Thesaurus)
C0035561 (UMLS 2011AA)

CL Item

Sigmoid Colon (Sigmoid Colon)

C12384 (NCI Thesaurus)
C0227391 (UMLS 2011AA)

CL Item

Sinuses (Sinuses)

CL Item

Skin (Skin)

C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)

CL Item

Skull (Skull)

C12789 (NCI Thesaurus)
C0037303 (UMLS 2011AA)

CL Item

Spine, Cervical (Spine-C)

CL Item

Spine, Lumbar (Spine-L)

CL Item

Spine, Sacral (Spine-S)

CL Item

Spine, Thoracic (Spine-T)

CL Item

Spleen (Spleen)

C12432 (NCI Thesaurus)
C0037993 (UMLS 2011AA)

CL Item

Sternum (Sternum)

C12793 (NCI Thesaurus)
C0038293 (UMLS 2011AA)

CL Item

Stomach (Stomach)

C12391 (NCI Thesaurus)
C0038351 (UMLS 2011AA)

CL Item

Testicle (Testicle)

C12412 (NCI Thesaurus)
C0039597 (UMLS 2011AA)

CL Item

Throat (Throat)

CL Item

Thyroid (Thyroid)

CL Item

Tibia (Tibia)

C12800 (NCI Thesaurus)
C0040184 (UMLS 2011AA)

CL Item

Ulna (Ulna)

CL Item

Ureter (Ureter)

C12416 (NCI Thesaurus)
C0041951 (UMLS 2011AA)

CL Item

Uterus (Uterus)

C12405 (NCI Thesaurus)
C0042149 (UMLS 2011AA)

CL Item

Vagina (Vagina)

C12407 (NCI Thesaurus)
C0042232 (UMLS 2011AA)

DiseaseDiagnosisTermName

Item

Disease Term

text

C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)

Histology/CytopathologyDescription

Item

Histology/Cytopathology Description

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25704 (NCI Thesaurus ValueDomain-2)
C1527021 (UMLS 2011AA ValueDomain-2)
C16681 (NCI Thesaurus ObjectClass)
C0019638 (UMLS 2011AA ObjectClass)
CL282989 (NCI Metathesaurus Property)

DiseaseStageCode

Item

Disease Stage

text

C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus Property)
C1300072 (UMLS 2011AA Property)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ValueDomain-2)
C0012634 (UMLS 2011AA ValueDomain-2)
C16899 (NCI Thesaurus ValueDomain-3)
C1300072 (UMLS 2011AA ValueDomain-3)

CL.7

Code List

Disease Stage

CL Item

Stage 0 (0)

C28051 (NCI Thesaurus)
C0441763 (UMLS 2011AA)

CL Item

Stage A (A)

C28056 (NCI Thesaurus)
C0441778 (UMLS 2011AA)

CL Item

Stage B (B)

C28057 (NCI Thesaurus)
C0441781 (UMLS 2011AA)

CL Item

Stage C (C)

C28060 (NCI Thesaurus)
C0441785 (UMLS 2011AA)

CL Item

Stage D (D)

C28061 (NCI Thesaurus)
C0441789 (UMLS 2011AA)

CL Item

Stage D0 (D0)

CL Item

Stage D1 (D1)

C28062 (NCI Thesaurus)
C0441790 (UMLS 2011AA)

CL Item

Stage D2 (D2)

C28063 (NCI Thesaurus)
C0441791 (UMLS 2011AA)

CL Item

Stage D3 (D3)

CL Item

Stage I (I)

C27966 (NCI Thesaurus)
C0441766 (UMLS 2011AA)

CL Item

Stage Ia (IA)

C27975 (NCI Thesaurus)
C0456595 (UMLS 2011AA)

CL Item

Stage Ib (IB)

C27976 (NCI Thesaurus)
C0456597 (UMLS 2011AA)

CL Item

Stage Ii (II)

C28054 (NCI Thesaurus)
C0441767 (UMLS 2011AA)

CL Item

Stage Iia (IIA)

C27967 (NCI Thesaurus)
C0441768 (UMLS 2011AA)

CL Item

Stage Iib (IIB)

C27968 (NCI Thesaurus)
C0441769 (UMLS 2011AA)

CL Item

Stage Iii (III)

C27970 (NCI Thesaurus)
C0441771 (UMLS 2011AA)

CL Item

Stage Iiia (IIIA)

C27977 (NCI Thesaurus)
C0456598 (UMLS 2011AA)

CL Item

Stage Iiib (IIIB)

C27978 (NCI Thesaurus)
C0456599 (UMLS 2011AA)

CL Item

Stage Iiic (IIIC)

C27982 (NCI Thesaurus)
C0456608 (UMLS 2011AA)

CL Item

Stage Iv (IV)

C27971 (NCI Thesaurus)
C0441772 (UMLS 2011AA)

CL Item

Stage Iva (IVA)

C27979 (NCI Thesaurus)
C0456600 (UMLS 2011AA)

CL Item

Stage Ivb (IVB)

C27980 (NCI Thesaurus)
C0456601 (UMLS 2011AA)

DiseaseCDUSCode

Item

Disease CDUS Code (This is a derived field and may be displayed on the form, if needed.)

text

C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C19992 (NCI Thesaurus ObjectClass-2)
C1516607 (UMLS 2011AA ObjectClass-2)
C25162 (NCI Thesaurus Property)
C0805701 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property-2)
C0012634 (UMLS 2011AA Property-2)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)

CONSENT

Item Group

Consent

HistologicConfirmationDate

Item

Histologic Confirmation Date

date

C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25526 (NCI Thesaurus ObjectClass)
C0205462 (UMLS 2011AA ObjectClass)
CL232278 (NCI Metathesaurus ObjectClass)

Diagnosis Date

Item

Diagnosis Date

date

C25164 (NCI Thesaurus ValueDomain)
C2316983 (UMLS CUI-1)
C25626 (NCI Thesaurus Property)
C15220 (NCI Thesaurus ObjectClass)

InformedConsentFormSignedDate

Item

ICF Signed Date

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C16468 (NCI Thesaurus ObjectClass)
C0009797 (UMLS 2011AA ObjectClass)
C25679 (NCI Thesaurus Property)

InformedConsentVersion

Item

Informed Consent Version

text

C16735 (NCI Thesaurus ObjectClass)
C0021430 (UMLS 2011AA ObjectClass)
C25714 (NCI Thesaurus Property)
C0333052 (UMLS 2011AA Property)

HistopathologicDifferentiationTextGrade

Item

Histopathologic Differentiation Text Grade

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C18000 (NCI Thesaurus Property)
C0919553 (UMLS 2011AA Property)
C18000 (NCI Thesaurus ValueDomain-2)
C0919553 (UMLS 2011AA ValueDomain-2)

CL.8

Code List

Histopathologic Differentiation Text Grade

CL Item

High Grade (High Grade)

C14158 (NCI Thesaurus)
C0205082 (UMLS 2011AA)

CL Item

Low Grade (Low Grade)

C14161 (NCI Thesaurus)
C1282907 (UMLS 2011AA)

CL Item

Moderately Differentiated (Moderately)

C14162 (NCI Thesaurus)
C0205616 (UMLS 2011AA)

CL Item

Not Applicable (N/A)

C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)

CL Item

Poorly Differentiated (Poorly)

C14167 (NCI Thesaurus)
C0205617 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Well Differentiated (Well)

C14171 (NCI Thesaurus)
C0205615 (UMLS 2011AA)

EnrollmentTreatmentStudyAssignmentCode

Item

Treatment Assignment Code at Enrollment

text

C15368 (NCI Thesaurus ObjectClass)
C19992 (NCI Thesaurus ObjectClass-2)
C1516607 (UMLS 2011AA ObjectClass)
C25162 (NCI Thesaurus Property)
C0805701 (UMLS 2011AA Property)
C25426 (NCI Thesaurus Property-2)
C1516050 (UMLS 2011AA Property-2)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C37948 (NCI Thesaurus ValueDomain-2)
C1516879 (UMLS 2011AA ValueDomain-2)
C25426 (NCI Thesaurus ValueDomain-3)
C1516050 (UMLS 2011AA ValueDomain-3)
C49656 (NCI Thesaurus ValueDomain-4)
C0087111 (UMLS 2011AA ValueDomain-4)

VITAL SIGNS

Item Group

Vital Signs

EvaluationDate

Item

Evaluation Date

date

C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)

LabCollectionTime

Item

Lab Collection Time

time

C25453 (NCI Thesaurus Property)
C1516698 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property-2)
C0040223 (UMLS 2011AA Property-2)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)

PersonHeightMeasurement

Item

Height (cm)

float

C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS 2011AA Property)

BodyWeightinKilograms

Item

Body Weight in Kilograms

float

C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C13041 (NCI Thesaurus ObjectClass)
C1268086 (UMLS 2011AA ObjectClass)
C25208 (NCI Thesaurus Property)
C0043100 (UMLS 2011AA Property)

Body Surface Area

Item

BSA

float

C25190 (NCI Thesaurus ObjectClass)
C0005902 (UMLS CUI-1)
C25712 (NCI Thesaurus ValueDomain)
C25157 (NCI Thesaurus Property)

ZubrodPerformanceStatusScore

Item

Zubrod Performance Status Score

text

C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C1518965 (UMLS 2011AA ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)

CL.9

Code List

Zubrod Performance Status Score

CL Item

Normal Activity (0)

CL Item

Symptoms, But Nearly Fully Ambulatory (1)

CL Item

Some Bed Time, But Needs To Be In Bed <50% Of Normal Daytime (2)

CL Item

Needs To Be In Bed > 50% Of Normal Daytime (3)

CL Item

Unable To Get Out Of Bed (4)

KarnofskyPerformanceStatusScore

Item

Karnofsky Performance Status Score

text

C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C1518965 (UMLS 2011AA ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)

CL.10

Code List

Karnofsky Performance Status Score

CL Item

Dead (0)

CL Item

Moribund, Fatal Processes Progressing Rapidly (10)

CL Item

Very Sick, Hospitalization Indicated. Death Not Imminent (20)

CL Item

Severely Disabled, Hospitalization Indicated. Death Not Imminent (30)

CL Item

Disabled, Requires Special Care And Assistance (40)

CL Item

Requires Considerable Assistance And Frequent Medical Care (50)

CL Item

Requires Occasional Assistance, But Is Able To Care For Most Of His/her Needs (60)

CL Item

Cares For Self, Unable To Carry On Normal Activity Or To Do Active Work (70)

CL Item

Normal Activity With Effort; Some Signs Or Symptoms Of Disease (80)

CL Item

Able To Carry On Normal Activity; Minor Signs Or Symptoms Of Disease (90)

CL Item

Normal, No Complaints, No Evidence Of Disease (100)

LanskyPerformanceStatusScore

Item

Lansky Performance Status Score

text

C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C1518965 (UMLS 2011AA ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)

CL.11

Code List

Lansky Performance Status Score

CL Item

Unresponsive (0)

CL Item

No Play; Does Not Get Out Of Bed. (10)

CL Item

Fully Active, Normal (100)

CL Item

Often Sleeping; Play Entirely Limited To Very Passive Activities. (20)

CL Item

In Bed; Needs Assistance Even For Quiet Play. (30)

CL Item

Mostly In Bed; Participates In Quiet Activities. (40)

CL Item

Gets Dressed, But Lies Around Much Of The Day; No Active Play, Able To Participate In All Quiet Play And Activities. (50)

CL Item

Up And Around, But Minimal Active Play; Keeps Busy With Quieter Activities. (60)

CL Item

Both Greater Restriction Of And Less Time Spent In Play Activity (70)

CL Item

Active, But Tires More Quickly (80)

CL Item

Minor Restrictions In Physically Strenuous Activity (90)

COMMENTS

Item Group

Comments

NoteDate

Item

Note Date

date

C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C1317574 (NCI Metathesaurus ObjectClass)

Research Comments

Item

Research Comments Text

text

C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)

Zum Seitenanfang zurückkehren

ID

Beschreibung

Link

Stichworte

Versionen (4)

Hochgeladen am

DOI

Lizenz

Modell Kommentare :

Itemgroup Kommentare für :

Item Kommentare für :

On-Study - ENROLLMENT - 2393048v1.2

Dates will appear as 'DD-MON-YYYY'

Beschreibung

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Datentyp

Alias

Beschreibung

Beschreibung

Datentyp

Alias