ID

6548

Description

AMC-045 Death Form (F04) Cisplatin, Fluorouracil, Cetuximab, and Radiation Therapy in Treating Patients With HIV and Stage I, Stage II, or Stage III Anal Cancer NCT00324415 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=72844558-61AB-0B0B-E040-BB89AD4314AD

Link

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

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
Uploaded on

January 8, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Death Form (F04) Anal Cancer (NCT00324415)

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-045 Death Form (F04)
    1. No Instruction available.
Date of Death (mm/dd/yyyy)
Description

DeathDocumentedDate

Data type

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)
Description

Treatment Status

Data type

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0749659
NCI Thesaurus Property
C25365
Last Date (any modality of) protocol therapy was given (mm/dd/yyyy)
Description

Treatment End Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1531784
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25275
NCI Thesaurus Property-2
C25496
Primary cause of death
Description

AcquiredImmunodeficiencySyndromePatientPrimaryDeathReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C2851
UMLS 2011AA ObjectClass-2
C0001175
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus Property-2
C25251
UMLS 2011AA Property-2
C0205225
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Contributing cause of death
Description

AcquiredImmunodeficiencySyndromePatientSecondaryDeathReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C2851
UMLS 2011AA ObjectClass-2
C0001175
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus Property-2
C25667
UMLS 2011AA Property-2
C0175668
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Specify
Description

AcquiredImmunodeficiencySyndromePatientSecondaryDeathSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C2851
UMLS 2011AA ObjectClass-2
C0001175
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus Property-2
C25667
UMLS 2011AA Property-2
C0175668
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Describe cause of death
Description

Cause of Death, specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C0007465
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1521902
NCI Thesaurus Property
C28554
Source of death information
Description

AcquiredImmunodeficiencySyndromePatientDeathSource

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus ObjectClass-2
C2851
UMLS 2011AA ObjectClass-2
C0001175
NCI Thesaurus ValueDomain
C25683
UMLS 2011AA ValueDomain
C0449416
Other, specify
Description

PatientDeathSourceSpecify

Data type

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
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-045 Death Form (F04)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
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)
C0749659 (UMLS CUI-1)
C25365 (NCI Thesaurus 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)
Treatment End Date
Item
Last Date (any modality of) protocol therapy was given (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C1531784 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C25496 (NCI Thesaurus Property-2)
Item
Primary cause of death
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2851 (NCI Thesaurus ObjectClass-2)
C0001175 (UMLS 2011AA ObjectClass-2)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
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-2)
C0001175 (UMLS 2011AA ObjectClass-2)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C25667 (NCI Thesaurus Property-2)
C0175668 (UMLS 2011AA Property-2)
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-2)
C0001175 (UMLS 2011AA ObjectClass-2)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C25667 (NCI Thesaurus Property-2)
C0175668 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Cause of Death, specify
Item
Describe cause of death
text
C25685 (NCI Thesaurus ValueDomain)
C0007465 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-2)
C28554 (NCI Thesaurus 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-2)
C0001175 (UMLS 2011AA ObjectClass-2)
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)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
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