ID

585

Descrição

AMC-046 Concomitant Medication Form (MED) 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=7D8985E5-2DD3-08A5-E040-BB89AD434A3B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7D8985E5-2DD3-08A5-E040-BB89AD434A3B

Palavras-chave

Versões (3)
  1. 26/08/2012 26/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

26 de agosto de 2012

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Anal Cancer NCT00550589 Treatment - AMC-046 Concomitant Medication Form (MED) - 2989341v1.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: AMC-046 Concomitant Medication Form (MED)
    1. No Instruction available.
Ccrr Module For Concomitant Antiretroviral Medications - Rf08
Descrição

Ccrr Module For Concomitant Antiretroviral Medications - Rf08

Agent Name
Descrição

AgentName

Tipo de dados

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain
C1708
UMLS 2011AA ValueDomain
C0450442
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
Dose Level Start Date
Descrição

AgentDoseLevelBeginDate

Tipo de dados

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)
Descrição

DailyAgentTotalDose

Tipo de dados

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
Descrição

AgentConcomitantAdministrationUOM

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25730
UMLS 2011AA Property
C0521115
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus ValueDomain
C25709
UMLS 2011AA ValueDomain
C1519795
Other, specify
Descrição

AgentConcomitantAdministrationSpecify

Tipo de dados

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
Descrição

AgentAdministeredFrequency

Tipo de dados

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
Descrição

AgentAdministeredFrequencySpecify

Tipo de dados

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
Descrição

Anti-RetroviralAgentsAdministeredInd-2

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Metathesaurus ObjectClass
C0599685
Please provide indication (If "no")
Descrição

Anti-RetroviralAgentsNotAdministeredReason

Tipo de dados

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
Descrição

ConcomitantMedicationAdministrationCurrentInd-3

Tipo de dados

text

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
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ValueDomain
C25471
UMLS 2011AA ValueDomain
C0521116
Date last taken (If "no" mm/dd/yyyy)
Descrição

ConcomitantMedicationAdministrationLastDate

Tipo de dados

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
Descrição

Comments

Comments
Descrição

ResearchCommentsText

Tipo de dados

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 Formulários
  1. StudyEvent: AMC-046 Concomitant Medication Form (MED)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Ccrr Module For Concomitant Antiretroviral Medications - Rf08
AgentName
Item
Agent Name
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C0450442 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
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)
C0450442 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus Property)
C0521115 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25709 (NCI Thesaurus ValueDomain)
C1519795 (UMLS 2011AA ValueDomain)
CL.1
Code List
Units
CL Item
Milligram (Milligram)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
CL Item
Microgram (Microgram)
CL Item
Milliliter (Milliliter)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Unit (Unit)
C44278 (NCI Thesaurus)
C0439148 (UMLS 2011AA)
CL Item
International Unit (International Unit)
C28255 (NCI Thesaurus)
CL Item
Capsules (Capsules)
CL Item
Tablets (Tablets)
CL Item
Drops (Drops)
C69442 (NCI Thesaurus)
C2347093 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
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)
Item
Is this an antiretroviral agent
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0599685 (NCI Metathesaurus ObjectClass)
CL.3
Code List
Is this an antiretroviral agent
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
Item
Is use of this agent ongoing
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ValueDomain)
C0521116 (UMLS 2011AA ValueDomain)
CL.4
Code List
Is use of this agent ongoing
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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
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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