ID

523

Descripción

AMC-046 Death Form (F04) Cidofovir in Treating HIV-Infected Patients With High-Grade Squamous Intraepithelial Lesions of the Skin Near the Anus Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7D8985E5-2EC8-08A5-E040-BB89AD434A3B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7D8985E5-2EC8-08A5-E040-BB89AD434A3B

Palabras clave

Versiones (2)
  1. 26/8/12 26/8/12 -
  2. 8/1/15 8/1/15 - Martin Dugas
Subido en

26 de agosto de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Anal Cancer NCT00550589 Follow-Up - AMC-046 Death Form (F04) - 2989462v1.0

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: AMC-046 Death Form (F04)
    1. No Instruction available.
Ccrr Module For Death Form - Rf04
Descripción

Ccrr Module For Death Form - Rf04

Date of Death (mm/dd/yyyy)
Descripción

DeathDocumentedDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
Treatment Status (at time of death)
Descripción

TreatmentStatusType

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Last Date (any modality of) protocol therapy was given (mm/dd/yyyy)
Descripción

TreatmentEndDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property
C25496
UMLS 2011AA Property
C2746065
Primary cause of death
Descripción

AcquiredImmunodeficiencySyndromePatientPrimaryDeathReason

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C2851
UMLS 2011AA ObjectClass
C0001175
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus Property
C25251
UMLS 2011AA Property
C0205225
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Contributing cause of death
Descripción

AcquiredImmunodeficiencySyndromePatientSecondaryDeathReason

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C2851
UMLS 2011AA ObjectClass
C0001175
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus Property
C25667
UMLS 2011AA Property
C0175668
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Specify
Descripción

AcquiredImmunodeficiencySyndromePatientSecondaryDeathSpecify

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C2851
UMLS 2011AA ObjectClass
C0001175
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus Property
C25667
UMLS 2011AA Property
C0175668
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Describe cause of death
Descripción

PatientDeathSpecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
Source of death information
Descripción

AcquiredImmunodeficiencySyndromePatientDeathSource

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus ObjectClass
C2851
UMLS 2011AA ObjectClass
C0001175
NCI Thesaurus ValueDomain
C25683
UMLS 2011AA ValueDomain
C0449416
Other, specify
Descripción

PatientDeathSourceSpecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
Comments
Descripción

Comments

Comments
Descripción

ResearchCommentsText

Tipo de datos

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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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: AMC-046 Death Form (F04)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Ccrr Module For Death Form - Rf04
DeathDocumentedDate
Item
Date of Death (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
Item
Treatment Status (at time of death)
text
C15368 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.1
Code List
Treatment Status (at time of death)
CL Item
On Study, On Protocol Treatment (On study, on protocol treatment)
CL Item
On Study, Off Protocol Treatment (On study, off protocol treatment)
CL Item
Off Study (Off study)
TreatmentEndDate
Item
Last Date (any modality of) protocol therapy was given (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
Item
Primary cause of death
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2851 (NCI Thesaurus ObjectClass)
C0001175 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.2
Code List
Primary cause of death
CL Item
Due To Non-malignancy Complications Of Hiv Disease (Due to Non-malignancy complications of HIV disease)
CL Item
Due To Other Cause, Specify (Due to other cause)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To Second Primary Or Other Malignancy (Due to second primary or other malignancy)
CL Item
Due To This Disease (Due to this disease)
Item
Contributing cause of death
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2851 (NCI Thesaurus ObjectClass)
C0001175 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C25667 (NCI Thesaurus Property)
C0175668 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.3
Code List
Contributing cause of death
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Second Primary Or Other Malignancy (Due to second primary or other malignancy)
CL Item
Due To Non-malignancy Complications Of Hiv Disease (Due to Non-malignancy complications of HIV disease)
CL Item
Due To Other Cause, Specify (Due to other cause)
AcquiredImmunodeficiencySyndromePatientSecondaryDeathSpecify
Item
Specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2851 (NCI Thesaurus ObjectClass)
C0001175 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C25667 (NCI Thesaurus Property)
C0175668 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientDeathSpecify
Item
Describe cause of death
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
Item
Source of death information
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C2851 (NCI Thesaurus ObjectClass)
C0001175 (UMLS 2011AA ObjectClass)
C25683 (NCI Thesaurus ValueDomain)
C0449416 (UMLS 2011AA ValueDomain)
CL.4
Code List
Source of death information
CL Item
Autopsy (Autopsy)
C25153 (NCI Thesaurus)
C0004398 (UMLS 2011AA)
CL Item
Histological Evidence Was The Source Of Information On The Patient's Death (Histological evidence)
CL Item
Clinical Evidence Was The Source Of Information On The Patient's Death (Clinical evidence)
CL Item
Contact With Physician (Contact with physician)
CL Item
Information From Friends And Relatives (Information from friends and relatives)
CL Item
Death Certificate Was The Source Of Information On The Patient's Death (Death certificate)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientDeathSourceSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
Item Group
Comments
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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