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ID

6067

Description

AMC-045 Concomitant Medication Form (MED) Cisplatin, Fluorouracil, Cetuximab, and Radiation Therapy in Treating Patients With HIV and Stage I, Stage II, or Stage III Anal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=72844558-61F6-0B0B-E040-BB89AD4314AD

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=72844558-61F6-0B0B-E040-BB89AD4314AD

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 11/28/14 11/28/14 - Martin Dugas
  3. 4/13/21 4/13/21 - Dr. rer. medic Philipp Neuhaus
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November 28, 2014

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Creative Commons BY-NC 3.0 Legacy
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    Anal Cancer NCT00324415 Treatment - AMC-045 Concomitant Medication Form (MED) - 2936871v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: AMC-045 Concomitant Medication Form (MED)
      1. No Instruction available.
    Ccrr Module For Concomitant Antiretroviral Medications - Rf08
    Description

    Ccrr Module For Concomitant Antiretroviral Medications - Rf08

    Alias
    UMLS CUI-1
    C2347852
    Agent Name
    Description

    Agent Name

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus ValueDomain
    C1708
    NCI Thesaurus ValueDomain
    C42614
    UMLS CUI-1
    C1372955
    Dose Level Start Date
    Description

    AgentDoseLevelBeginDate

    Data type

    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)
    Description

    DailyAgentTotalDose

    Data type

    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
    Description

    AgentConcomitantAdministrationUOM

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus Property
    C25730
    NCI Thesaurus Property
    C25409
    NCI Thesaurus ValueDomain
    C25709
    UMLS CUI-1
    C1519795
    Other, specify
    Description

    AgentConcomitantAdministrationSpecify

    Data type

    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
    Description

    AgentAdministeredFrequency

    Data type

    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
    Description

    AgentAdministeredFrequencySpecify

    Data type

    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
    Description

    Anti-RetroviralAgentsAdministeredInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    NCI Thesaurus Property
    C25382
    NCI Metathesaurus ObjectClass
    C0599685
    UMLS CUI-1
    C1512698
    UMLS CUI-2
    C1521801
    Please provide indication (If "no")
    Description

    Anti-RetroviralAgentsNotAdministeredReason

    Data type

    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
    Description

    ConcomitantMedicationAdministrationCurrentInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C459
    NCI Thesaurus ObjectClass
    C25730
    NCI Thesaurus Property
    C25409
    NCI Thesaurus ValueDomain
    C38148
    NCI Thesaurus ValueDomain
    C25471
    UMLS CUI-1
    C0013227
    UMLS CUI-2
    C0521115
    UMLS CUI-3
    C1533734
    UMLS CUI-4
    C1512699
    UMLS CUI-5
    C0521116
    Date last taken (If "no" mm/dd/yyyy)
    Description

    ConcomitantMedicationAdministrationLastDate

    Data type

    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
    Description

    Comments

    Alias
    UMLS CUI-1
    C0947611
    Comments
    Description

    ResearchCommentsText

    Data type

    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 forms
    1. StudyEvent: AMC-045 Concomitant Medication Form (MED)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Ccrr Module For Concomitant Antiretroviral Medications - Rf08
    C2347852 (UMLS CUI-1)
    Agent
    Item
    Agent Name
    text
    C25364 (NCI Thesaurus Property)
    C1708 (NCI Thesaurus ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C42614 (NCI Thesaurus ValueDomain)
    C1372955 (UMLS CUI-1)
    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)
    C25730 (NCI Thesaurus Property)
    C25409 (NCI Thesaurus Property)
    C25709 (NCI Thesaurus ValueDomain)
    C1519795 (UMLS CUI-1)
    CL.1
    Code List
    Units
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Milligram (mg)
    CL Item
    Microgram (µg)
    CL Item
    Milliliter (ml)
    CL Item
    Unit (U)
    CL Item
    International Unit (IU)
    CL Item
    Capsules (Caps)
    CL Item
    Tablets (Tabl)
    CL Item
    Drops (Dr)
    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)
    Anti-RetroviralAgentsAdministeredInd-2
    Item
    Is this an antiretroviral agent
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C25382 (NCI Thesaurus Property)
    C0599685 (NCI Metathesaurus ObjectClass)
    C1512698 (UMLS CUI-1)
    C1521801 (UMLS CUI-2)
    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)
    ConcomitantMedicationAdministrationCurrentInd-3
    Item
    Is use of this agent ongoing
    boolean
    C459 (NCI Thesaurus ObjectClass)
    C25730 (NCI Thesaurus ObjectClass)
    C25409 (NCI Thesaurus Property)
    C38148 (NCI Thesaurus ValueDomain)
    C25471 (NCI Thesaurus ValueDomain)
    C0013227 (UMLS CUI-1)
    C0521115 (UMLS CUI-2)
    C1533734 (UMLS CUI-3)
    C1512699 (UMLS CUI-4)
    C0521116 (UMLS CUI-5)
    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
    C0947611 (UMLS CUI-1)
    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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