ID

43432

Beschrijving

CALGB: ARTERIAL THROMBOEMBOLIC EVENT REPORT NCT00110214 Docetaxel and Prednisone With or Without Bevacizumab in Treating Patients With Prostate Cancer That Did Not Respond to Hormone Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EF4BCCC7-ECC6-11A8-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EF4BCCC7-ECC6-11A8-E034-0003BA3F9857

Trefwoorden

  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 21-06-15 21-06-15 -
  4. 20-09-21 20-09-21 -
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20 september 2021

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy

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    CALGB: ARTERIAL THROMBOEMBOLIC EVENT REPORT NCT00110214

    For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. If data are amended, circle amended items and check the "Yes" box.

    Header
    Beschrijving

    Header

    CALGB Form
    Beschrijving

    Form ID CALGB

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3262252
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass-2
    C25442
    CALGB Study No
    Beschrijving

    Protocol ID CALGB

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    CALGB Patient ID
    Beschrijving

    Trial subject ID CALGB

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    Start date of primary AE (^2)
    Beschrijving

    PrimaryAdverseEventBeginDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C25251
    UMLS 2011AA ObjectClass
    C0205225
    NCI Thesaurus ObjectClass-2
    C41331
    UMLS 2011AA ObjectClass-2
    C0877248
    NCI Thesaurus Property
    C25431
    UMLS 2011AA Property
    C0439659
    NCI Thesaurus Property-2
    C25275
    UMLS 2011AA Property-2
    C2745955
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25431
    UMLS 2011AA ValueDomain-2
    C0439659
    Endt date of primary AE (^2)
    Beschrijving

    PrimaryAdverseEventEndDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C25251
    UMLS 2011AA ObjectClass
    C0205225
    NCI Thesaurus ObjectClass-2
    C41331
    UMLS 2011AA ObjectClass-2
    C0877248
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    NCI Thesaurus Property-2
    C25496
    UMLS 2011AA Property-2
    C2746065
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Are data amended
    Beschrijving

    Data amended

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Patient demographics
    Beschrijving

    Patient demographics

    Patient Initials
    Beschrijving

    Patient Initials

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Patient Hospital No
    Beschrijving

    Patient Hospital No

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C0421459
    NCI Thesaurus Property
    C16960
    NCI Thesaurus Property-2
    C25364
    NCI Thesaurus ObjectClass
    C16696
    Institution/Affiliate
    Beschrijving

    Institution Name

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Participating Group
    Beschrijving

    Participating Group

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2347449
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    Participating Group Study No
    Beschrijving

    Study Number Participating Group

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Participating Group Patient ID
    Beschrijving

    Trial subject ID Participating Group

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    ARTERIAL THROMBOEMBOLIC EVENT REPORT
    Beschrijving

    ARTERIAL THROMBOEMBOLIC EVENT REPORT

    Course number on which event occurred (s)
    Beschrijving

    TreatmentCycleAdverseEventOccurrenceNumber

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25472
    UMLS 2011AA ObjectClass
    C1511572
    NCI Metathesaurus ObjectClass
    C0087111
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    NCI Metathesaurus Property
    C0683157
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Total number of courses to date
    Beschrijving

    AgentCourseCount

    Datatype

    float

    Alias
    NCI Thesaurus ValueDomain
    C25463
    UMLS 2011AA ValueDomain
    C0750480
    NCI Thesaurus Property
    C25379
    UMLS 2011AA Property
    C0750729
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    Description of event (s Record if not submitting AdEERS report.)
    Beschrijving

    AdverseEventDescriptiveText

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C41331
    UMLS 2011AA ObjectClass
    C0877248
    NCI Metathesaurus Property
    C0678257
    MedDRA code
    Beschrijving

    MedDRACode

    Datatype

    float

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Metathesaurus ObjectClass
    CL104089
    Adverse event
    Beschrijving

    CTC Adverse Event Term

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C1516728
    NCI Thesaurus ObjectClass
    C49704
    UMLS CUI-2
    C2826934
    NCI Thesaurus Property
    C45559
    Cardiac-ischemia/infarction Grade (Mark one with an X.)
    Beschrijving

    CommonToxicityCriteriaAdverseEventInfarctionGrade

    Datatype

    float

    Alias
    NCI Thesaurus ObjectClass
    C49704
    UMLS 2011AA ObjectClass
    C1516728
    NCI Thesaurus ValueDomain
    C18000
    UMLS 2011AA ValueDomain
    C0919553
    NCI Thesaurus Property
    C25738
    UMLS 2011AA Property
    C0021308
    CNS cerebrovascular ischemia Grade
    Beschrijving

    CommonToxicityCriteriaAdverseEventCTCAdverseEventsCentralNervousSystemCerebrovascularAccidentIschemiaGrade

    Datatype

    float

    Alias
    NCI Thesaurus Property
    C12438
    UMLS 2011AA Property
    C3714787
    NCI Thesaurus ObjectClass
    C49704
    UMLS 2011AA ObjectClass
    C1516728
    NCI Thesaurus ValueDomain
    C18000
    UMLS 2011AA ValueDomain
    C0919553
    NCI Metathesaurus Property
    C0038454
    Peripheral arterial ischemia Grade
    Beschrijving

    CommonToxicityCriteriaAdverseEventPeripheralArterialIschemiaGrade

    Datatype

    float

    Alias
    NCI Thesaurus ObjectClass
    C49704
    UMLS 2011AA ObjectClass
    C1516728
    NCI Thesaurus ValueDomain
    C18000
    UMLS 2011AA ValueDomain
    C0919553
    NCI Thesaurus Property
    C25233
    UMLS 2011AA Property
    C0205100
    NCI Metathesaurus Property
    CL163817
    CTC AE attribution code
    Beschrijving

    CTC Adverse Event Attribution Category

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS CUI-1
    C1706735
    NCI Thesaurus ObjectClass
    C49704
    NCI Thesaurus Property
    C25358
    Is primary AE (^2)
    Beschrijving

    PrimaryAdverseEventOccurrenceInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25251
    UMLS 2011AA ObjectClass
    C0205225
    NCI Thesaurus ObjectClass-2
    C41331
    UMLS 2011AA ObjectClass-2
    C0877248
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    CTC AE grade
    Beschrijving

    CTC Adverse Event Grade

    Datatype

    float

    Alias
    NCI Thesaurus ObjectClass
    C49704
    UMLS CUI-1
    C2985911
    NCI Thesaurus ValueDomain
    C18000
    NCI Thesaurus Property
    C25365
    Treatment of event (s Mark all that apply with an X.)
    Beschrijving

    AdverseEventTreatmentAdministeredType

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C41331
    UMLS 2011AA ObjectClass
    C0877248
    NCI Thesaurus Property
    C15368
    NCI Thesaurus ValueDomain-2
    C25382
    UMLS 2011AA ValueDomain-2
    C1521801
    Hospital admission date
    Beschrijving

    HospitalAdmissionDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16696
    UMLS 2011AA ObjectClass
    C0019994
    NCI Thesaurus Property
    C25385
    UMLS 2011AA Property
    C0809949
    Hospital discharge date
    Beschrijving

    HospitalDischargeDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16696
    UMLS 2011AA ObjectClass
    C0019994
    NCI Metathesaurus Property
    C0012621
    Surgery, specify
    Beschrijving

    AdverseEventTreatmentSurgicalProcedureSpecify

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C41331
    UMLS 2011AA ObjectClass
    C0877248
    NCI Thesaurus Property
    C15368
    Present status (Mark all that apply with an X.)
    Beschrijving

    CALGBAdverseEventPresentStatus

    Datatype

    text

    Alias
    NCI Thesaurus Property
    C25626
    UMLS 2011AA Property
    C0150312
    NCI Thesaurus ObjectClass
    C25442
    UMLS 2011AA ObjectClass
    C1516238
    NCI Thesaurus ObjectClass-2
    C41331
    UMLS 2011AA ObjectClass-2
    C0877248
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Removed from protocol treatment, specify date
    Beschrijving

    OffTreatmentDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25601
    UMLS 2011AA ObjectClass
    C1518544
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Completed by
    Beschrijving

    Person Completing Form

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    Date form completed
    Beschrijving

    Date Form Completed

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1115437
    NCI Thesaurus ObjectClass
    C40988
    NCI Thesaurus Property
    C25250
    NCI Thesaurus ValueDomain-2
    C25367

    Similar models

    For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. If data are amended, circle amended items and check the "Yes" box.

    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Header
    Form ID CALGB
    Item
    CALGB Form
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3262252 (UMLS CUI-1)
    C19464 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus ObjectClass-2)
    Protocol ID CALGB
    Item
    CALGB Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    Trial subject ID CALGB
    Item
    CALGB Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    PrimaryAdverseEventBeginDate
    Item
    Start date of primary AE (^2)
    date
    C25251 (NCI Thesaurus ObjectClass)
    C0205225 (UMLS 2011AA ObjectClass)
    C41331 (NCI Thesaurus ObjectClass-2)
    C0877248 (UMLS 2011AA ObjectClass-2)
    C25431 (NCI Thesaurus Property)
    C0439659 (UMLS 2011AA Property)
    C25275 (NCI Thesaurus Property-2)
    C2745955 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    C0439659 (UMLS 2011AA ValueDomain-2)
    PrimaryAdverseEventEndDate
    Item
    Endt date of primary AE (^2)
    date
    C25251 (NCI Thesaurus ObjectClass)
    C0205225 (UMLS 2011AA ObjectClass)
    C41331 (NCI Thesaurus ObjectClass-2)
    C0877248 (UMLS 2011AA ObjectClass-2)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    C25496 (NCI Thesaurus Property-2)
    C2746065 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Data amended
    Item
    Are data amended
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    Patient demographics
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Patient Hospital No
    Item
    Patient Hospital No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0421459 (UMLS CUI-1)
    C16960 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    C16696 (NCI Thesaurus ObjectClass)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Participating Group
    Item
    Participating Group
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Participating Group Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Item Group
    ARTERIAL THROMBOEMBOLIC EVENT REPORT
    TreatmentCycleAdverseEventOccurrenceNumber
    Item
    Course number on which event occurred (s)
    text
    C25472 (NCI Thesaurus ObjectClass)
    C1511572 (UMLS 2011AA ObjectClass)
    C0087111 (NCI Metathesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    C0683157 (NCI Metathesaurus Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    AgentCourseCount
    Item
    Total number of courses to date
    float
    C25463 (NCI Thesaurus ValueDomain)
    C0750480 (UMLS 2011AA ValueDomain)
    C25379 (NCI Thesaurus Property)
    C0750729 (UMLS 2011AA Property)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    AdverseEventDescriptiveText
    Item
    Description of event (s Record if not submitting AdEERS report.)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus ObjectClass)
    C0877248 (UMLS 2011AA ObjectClass)
    C0678257 (NCI Metathesaurus Property)
    MedDRACode
    Item
    MedDRA code
    float
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CL104089 (NCI Metathesaurus ObjectClass)
    Item
    Adverse event
    text
    C25284 (NCI Thesaurus ValueDomain)
    C1516728 (UMLS CUI-1)
    C49704 (NCI Thesaurus ObjectClass)
    C2826934 (UMLS CUI-2)
    C45559 (NCI Thesaurus Property)
    Code List
    Adverse event
    CL Item
    Myocardial Ischaemia (Cardiac ischemia/infarction)
    C0151744 (NCI Metathesaurus)
    CL Item
    Cerebral Ischaemia (CNS cerebrovascular ischemia)
    C0917798 (NCI Metathesaurus)
    CL Item
    Peripheral Ischaemia Nos (Peripheral arterial ischemia)
    CommonToxicityCriteriaAdverseEventInfarctionGrade
    Item
    Cardiac-ischemia/infarction Grade (Mark one with an X.)
    float
    C49704 (NCI Thesaurus ObjectClass)
    C1516728 (UMLS 2011AA ObjectClass)
    C18000 (NCI Thesaurus ValueDomain)
    C0919553 (UMLS 2011AA ValueDomain)
    C25738 (NCI Thesaurus Property)
    C0021308 (UMLS 2011AA Property)
    CommonToxicityCriteriaAdverseEventCTCAdverseEventsCentralNervousSystemCerebrovascularAccidentIschemiaGrade
    Item
    CNS cerebrovascular ischemia Grade
    float
    C12438 (NCI Thesaurus Property)
    C3714787 (UMLS 2011AA Property)
    C49704 (NCI Thesaurus ObjectClass)
    C1516728 (UMLS 2011AA ObjectClass)
    C18000 (NCI Thesaurus ValueDomain)
    C0919553 (UMLS 2011AA ValueDomain)
    C0038454 (NCI Metathesaurus Property)
    CommonToxicityCriteriaAdverseEventPeripheralArterialIschemiaGrade
    Item
    Peripheral arterial ischemia Grade
    float
    C49704 (NCI Thesaurus ObjectClass)
    C1516728 (UMLS 2011AA ObjectClass)
    C18000 (NCI Thesaurus ValueDomain)
    C0919553 (UMLS 2011AA ValueDomain)
    C25233 (NCI Thesaurus Property)
    C0205100 (UMLS 2011AA Property)
    CL163817 (NCI Metathesaurus Property)
    Item
    CTC AE attribution code
    text
    C25664 (NCI Thesaurus ValueDomain)
    C1706735 (UMLS CUI-1)
    C49704 (NCI Thesaurus ObjectClass)
    C25358 (NCI Thesaurus Property)
    Code List
    CTC AE attribution code
    CL Item
    Unrelated (unrelated)
    C25328 (NCI Thesaurus)
    C0445356 (UMLS 2011AA)
    CL Item
    Unlikely (unlikely)
    CL Item
    Possible (possible)
    C0332149 (NCI Metathesaurus)
    CL Item
    Probable (probable)
    C0332148 (NCI Metathesaurus)
    CL Item
    Definite (definite)
    CL209464 (NCI Metathesaurus)
    PrimaryAdverseEventOccurrenceInd-2
    Item
    Is primary AE (^2)
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25251 (NCI Thesaurus ObjectClass)
    C0205225 (UMLS 2011AA ObjectClass)
    C41331 (NCI Thesaurus ObjectClass-2)
    C0877248 (UMLS 2011AA ObjectClass-2)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    CTC Adverse Event Grade
    Item
    CTC AE grade
    float
    C49704 (NCI Thesaurus ObjectClass)
    C2985911 (UMLS CUI-1)
    C18000 (NCI Thesaurus ValueDomain)
    C25365 (NCI Thesaurus Property)
    Item
    Treatment of event (s Mark all that apply with an X.)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus ObjectClass)
    C0877248 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus Property)
    C25382 (NCI Thesaurus ValueDomain-2)
    C1521801 (UMLS 2011AA ValueDomain-2)
    Code List
    Treatment of event (s Mark all that apply with an X.)
    CL Item
    Hospitalization (Hospitalization)
    CL Item
    Surgery (Surgery)
    C17173 (NCI Thesaurus)
    C0038894 (UMLS 2011AA)
    HospitalAdmissionDate
    Item
    Hospital admission date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16696 (NCI Thesaurus ObjectClass)
    C0019994 (UMLS 2011AA ObjectClass)
    C25385 (NCI Thesaurus Property)
    C0809949 (UMLS 2011AA Property)
    HospitalDischargeDate
    Item
    Hospital discharge date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16696 (NCI Thesaurus ObjectClass)
    C0019994 (UMLS 2011AA ObjectClass)
    C0012621 (NCI Metathesaurus Property)
    AdverseEventTreatmentSurgicalProcedureSpecify
    Item
    Surgery, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus ObjectClass)
    C0877248 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus Property)
    Item
    Present status (Mark all that apply with an X.)
    text
    C25626 (NCI Thesaurus Property)
    C0150312 (UMLS 2011AA Property)
    C25442 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS 2011AA ObjectClass)
    C41331 (NCI Thesaurus ObjectClass-2)
    C0877248 (UMLS 2011AA ObjectClass-2)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    Code List
    Present status (Mark all that apply with an X.)
    CL Item
    Removed From Protocol Treatment (Removed from protocol treatment)
    CL Item
    Resumed Protocol Treatment (Resumed protocol treatment)
    OffTreatmentDate
    Item
    Removed from protocol treatment, specify date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    Person Completing Form
    Item
    Completed by
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Date Form Completed
    Item
    Date form completed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1115437 (UMLS CUI-1)
    C40988 (NCI Thesaurus ObjectClass)
    C25250 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)

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