ID

7069

Description

The Division of Cancer Prevention's screening case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=516F6F73-F6A7-27F0-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=516F6F73-F6A7-27F0-E044-0003BA3F9857

Keywords

  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Eligibility - Screening - 2762748v1.0

No Instruction available.

  1. StudyEvent: Screening
    1. No Instruction available.
Screening
Description

Screening

DCP Protocol #
Description

Protocol ID NCI

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1513882
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C19202
Institution Code
Description

NationalCancerInstituteInstituteCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant ID
Description

ParticipantIdentifier

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25364
UMLS 2011AA ValueDomain
C0600091
Visit Type
Description

VisitTypeText

Data type

text

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Visit Date
Description

VisitDate

Data type

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Screening
Description

Screening

Date Screening Informed Consent Signed
Description

ScreeningInformedConsentSignedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C48261
UMLS 2011AA ObjectClass
C1710032
NCI Thesaurus ObjectClass-2
C16735
UMLS 2011AA ObjectClass-2
C0021430
NCI Thesaurus Property
C25679
Not Obtained (If the screening date is not applicable check box.)
Description

NotObtainedIndicator

Data type

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Metathesaurus ObjectClass
CL310460
NCI Metathesaurus ObjectClass-2
CL052458
NCI Metathesaurus ValueDomain
C0021212
Not Obtained (If the screening date is not applicable check box.)
Description

NotObtainedIndicator

Data type

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Metathesaurus ObjectClass
CL310460
NCI Metathesaurus ObjectClass-2
CL052458
NCI Metathesaurus ValueDomain
C0021212
Screening Date
Description

ScreenDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C48261
UMLS 2011AA Property
C1710032
NCI Thesaurus ObjectClass
C15207
Is the participant a screen failure? (If the participant is a screen failure, please select the primary reason for the screen failure.)
Description

ProtocolScreenIndicator

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C48261
UMLS 2011AA Property
C1710032
NCI Thesaurus ObjectClass
C15207
If yes, specify primary reason for screen failure (Select the primary reason for the screen failure.)
Description

ProtocolScreenFailureReasonType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ValueDomain-2
C25638
UMLS 2011AA ValueDomain-2
C0392360
NCI Thesaurus Property
C48261
UMLS 2011AA Property
C1710032
NCI Thesaurus ObjectClass
C15207
Other, Specify (Enter the free text for the primary reason for the screen failure.)
Description

OtherSpecifyText

Data type

text

Alias
NCI Thesaurus Property
C25685
UMLS 2011AA Property
C1521902
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus Property-2
C25638
UMLS 2011AA Property-2
C0392360
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Who referred participant?
Description

PatientReferralSourceName

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25683
UMLS 2011AA Property
C0449416
NCI Thesaurus Property-2
C52582
UMLS 2011AA Property-2
C0034927
NCI Thesaurus ValueDomain
C25683
UMLS 2011AA ValueDomain
C0449416
NCI Thesaurus ValueDomain-2
C42614
UMLS 2011AA ValueDomain-2
C0027365
NCI Thesaurus ValueDomain-3
C52582
UMLS 2011AA ValueDomain-3
C0034927
Other, specify
Description

PatientReferralSourceOtherSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25683
UMLS 2011AA Property
C0449416
NCI Thesaurus Property-2
C52582
UMLS 2011AA Property-2
C0034927
How did participant find out about the study?
Description

ParticipantDiscoverStudySourceName

Data type

text

Alias
NCI Thesaurus ObjectClass
C29867
UMLS 2011AA ObjectClass
C0679646
NCI Thesaurus Property
C63536
UMLS 2011AA Property
C2603343
NCI Thesaurus Property-2
C62262
UMLS 2011AA Property-2
C1880355
NCI Thesaurus ValueDomain
C25683
UMLS 2011AA ValueDomain
C0449416
NCI Thesaurus ValueDomain-2
C42614
UMLS 2011AA ValueDomain-2
C0027365
NCI Thesaurus ValueDomain-3
C62262
UMLS 2011AA ValueDomain-3
C1880355
Other, specify
Description

ParticipantDiscoverStudyOtherSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C29867
UMLS 2011AA ObjectClass
C0679646
NCI Thesaurus Property
C63536
UMLS 2011AA Property
C2603343
NCI Thesaurus Property-2
C62262
UMLS 2011AA Property-2
C1880355
Dcp Template Footer
Description

Dcp Template Footer

Protocol Title
Description

Protocol Title

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986303
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C42774
Protocol Version
Description

Protocol Version

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2985700
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25364
Protocol Version
Description

Protocol Version

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2985700
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25364
Protocol Date
Description

Protocol Version Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2985700
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C0011008
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain-2
C25367
Page #
Description

PageNumber

Data type

float

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Metathesaurus ObjectClass
C0439643
Total Page Number
Description

CaseReportFormTotalPageNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus Property-2
C25304
UMLS 2011AA Property-2
C0439810
NCI Thesaurus Property-3
C42783
UMLS 2011AA Property-3
C1704732
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
DCP Template Version
Description

DCPTemplateVersionText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Metathesaurus ObjectClass
C0728990
NCI Thesaurus Property
C25714
UMLS 2011AA Property
C0333052

Similar models

No Instruction available.

  1. StudyEvent: Screening
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Screening
Protocol ID NCI
Item
DCP Protocol #
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1513882 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C19202 (NCI Thesaurus Property-2)
NationalCancerInstituteInstituteCode
Item
Institution Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ParticipantIdentifier
Item
Participant ID
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
VisitTypeText
Item
Visit Type
text
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
VisitDate
Item
Visit Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
Item Group
Screening
ScreeningInformedConsentSignedDate
Item
Date Screening Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C48261 (NCI Thesaurus ObjectClass)
C1710032 (UMLS 2011AA ObjectClass)
C16735 (NCI Thesaurus ObjectClass-2)
C0021430 (UMLS 2011AA ObjectClass-2)
C25679 (NCI Thesaurus Property)
Item
Not Obtained (If the screening date is not applicable check box.)
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
CL310460 (NCI Metathesaurus ObjectClass)
CL052458 (NCI Metathesaurus ObjectClass-2)
C0021212 (NCI Metathesaurus ValueDomain)
Code List
Not Obtained (If the screening date is not applicable check box.)
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
Item
Not Obtained (If the screening date is not applicable check box.)
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
CL310460 (NCI Metathesaurus ObjectClass)
CL052458 (NCI Metathesaurus ObjectClass-2)
C0021212 (NCI Metathesaurus ValueDomain)
Code List
Not Obtained (If the screening date is not applicable check box.)
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
ScreenDate
Item
Screening Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C48261 (NCI Thesaurus Property)
C1710032 (UMLS 2011AA Property)
C15207 (NCI Thesaurus ObjectClass)
ProtocolScreenIndicator
Item
Is the participant a screen failure? (If the participant is a screen failure, please select the primary reason for the screen failure.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C48261 (NCI Thesaurus Property)
C1710032 (UMLS 2011AA Property)
C15207 (NCI Thesaurus ObjectClass)
Item
If yes, specify primary reason for screen failure (Select the primary reason for the screen failure.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25638 (NCI Thesaurus ValueDomain-2)
C0392360 (UMLS 2011AA ValueDomain-2)
C48261 (NCI Thesaurus Property)
C1710032 (UMLS 2011AA Property)
C15207 (NCI Thesaurus ObjectClass)
Code List
If yes, specify primary reason for screen failure (Select the primary reason for the screen failure.)
CL Item
Did Not Meet Eligibility Criteria, Specify (Did not meet eligibility criteria, specify)
CL Item
Investigator Decision (Investigator decision)
CL Item
Other, Specify (Other, specify)
CL Item
Participant Decision (Participant Decision)
OtherSpecifyText
Item
Other, Specify (Enter the free text for the primary reason for the screen failure.)
text
C25685 (NCI Thesaurus Property)
C1521902 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25638 (NCI Thesaurus Property-2)
C0392360 (UMLS 2011AA Property-2)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item
Who referred participant?
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25683 (NCI Thesaurus Property)
C0449416 (UMLS 2011AA Property)
C52582 (NCI Thesaurus Property-2)
C0034927 (UMLS 2011AA Property-2)
C25683 (NCI Thesaurus ValueDomain)
C0449416 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C0027365 (UMLS 2011AA ValueDomain-2)
C52582 (NCI Thesaurus ValueDomain-3)
C0034927 (UMLS 2011AA ValueDomain-3)
Code List
Who referred participant?
CL Item
Physician (Physician)
C25741 (NCI Thesaurus)
C0031831 (UMLS 2011AA)
CL Item
Health Care Provider (Health Care Provider)
C16666 (NCI Thesaurus)
C0018724 (UMLS 2011AA)
CL Item
Friend Family (Family/Friend)
C25173 (NCI Thesaurus)
C0015576 (UMLS 2011AA)
C72884 (NCI Thesaurus-3)
C0079382 (UMLS 2011AA-4)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
C0036588 (UMLS 2011AA)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientReferralSourceOtherSpecify
Item
Other, specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25683 (NCI Thesaurus Property)
C0449416 (UMLS 2011AA Property)
C52582 (NCI Thesaurus Property-2)
C0034927 (UMLS 2011AA Property-2)
Item
How did participant find out about the study?
text
C29867 (NCI Thesaurus ObjectClass)
C0679646 (UMLS 2011AA ObjectClass)
C63536 (NCI Thesaurus Property)
C2603343 (UMLS 2011AA Property)
C62262 (NCI Thesaurus Property-2)
C1880355 (UMLS 2011AA Property-2)
C25683 (NCI Thesaurus ValueDomain)
C0449416 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C0027365 (UMLS 2011AA ValueDomain-2)
C62262 (NCI Thesaurus ValueDomain-3)
C1880355 (UMLS 2011AA ValueDomain-3)
Code List
How did participant find out about the study?
CL Item
Physician (Physician)
C25741 (NCI Thesaurus)
C0031831 (UMLS 2011AA)
CL Item
Nurse (Nurse)
C20821 (NCI Thesaurus)
C0028661 (UMLS 2011AA)
CL Item
Friend Family (Family/Friend)
C25173 (NCI Thesaurus)
C0015576 (UMLS 2011AA)
C72884 (NCI Thesaurus-3)
C0079382 (UMLS 2011AA-4)
CL Item
Web Site National Cancer Institute (NCI web site)
C19202 (NCI Thesaurus)
C1513882 (UMLS 2011AA)
C67518 (NCI Thesaurus-3)
C2349146 (UMLS 2011AA-4)
CL Item
Written Material (Written material)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Specify Other (Other, specify)
C25685 (NCI Thesaurus)
C1521902 (UMLS 2011AA)
C17649 (NCI Thesaurus-3)
C0205394 (UMLS 2011AA-4)
ParticipantDiscoverStudyOtherSpecify
Item
Other, specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C29867 (NCI Thesaurus ObjectClass)
C0679646 (UMLS 2011AA ObjectClass)
C63536 (NCI Thesaurus Property)
C2603343 (UMLS 2011AA Property)
C62262 (NCI Thesaurus Property-2)
C1880355 (UMLS 2011AA Property-2)
Item Group
Dcp Template Footer
Protocol Title
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C2986303 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C42774 (NCI Thesaurus Property)
Protocol Version
Item
Protocol Version
text
C25704 (NCI Thesaurus ValueDomain)
C2985700 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Protocol Version
Item
Protocol Version
text
C25704 (NCI Thesaurus ValueDomain)
C2985700 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Protocol Version Date
Item
Protocol Date
date
C25164 (NCI Thesaurus ValueDomain)
C2985700 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
PageNumber
Item
Page #
float
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0439643 (NCI Metathesaurus ObjectClass)
CaseReportFormTotalPageNumber
Item
Total Page Number
text
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25304 (NCI Thesaurus Property-2)
C0439810 (UMLS 2011AA Property-2)
C42783 (NCI Thesaurus Property-3)
C1704732 (UMLS 2011AA Property-3)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
DCPTemplateVersionText
Item
DCP Template Version
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C0728990 (NCI Metathesaurus ObjectClass)
C25714 (NCI Thesaurus Property)
C0333052 (UMLS 2011AA Property)

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial