ID

7083

Description

The Division of Cancer Prevention's tobacco assessment case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=519D5ABC-8BA7-5C35-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=519D5ABC-8BA7-5C35-E044-0003BA3F9857

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Tobacco Use Assessment - 2764420v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Tobacco Use Assessment
    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
Tobacco Assessment
Description

Tobacco Assessment

Have you smoked 100 cigarettes or more during your entire lifetime?
Description

SmokingHistoryLifetimeIndicator

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Section 1
Description

Section 1

Age in years
Description

AgeBeganSmokinginYears

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property-2
C18270
UMLS 2011AA Property-2
C0700219
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C29848
UMLS 2011AA ValueDomain-2
C0439234
NCI Thesaurus ValueDomain-3
C25150
UMLS 2011AA ValueDomain-3
C0001779
At what age did you begin smoking regularly?
Description

ParticipantCigaretteSmokingRegularType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property-2
C18270
UMLS 2011AA Property-2
C0700219
Do you currently smoke cigarettes regularly?
Description

CigaretteUseCurrentStatus

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C1802
UMLS 2011AA ObjectClass
C0677453
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
Age in years
Description

AgeDiscontinuedSmokinginYears

Data type

float

Alias
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Thesaurus Property
C25484
UMLS 2011AA Property
C1444662
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C29848
UMLS 2011AA ValueDomain-2
C0439234
NCI Thesaurus ValueDomain-3
C25150
UMLS 2011AA ValueDomain-3
C0001779
At what age did you stop smoking cigarettes on a regular basis?
Description

ParticipantCigaretteSmokingDiscontinuedRegularType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25484
UMLS 2011AA Property
C1444662
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
Years (How many years have you been smoking or did smoke regularly?)
Description

CigarettesSmokingYearNumber

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C1802
UMLS 2011AA ObjectClass
C0677453
NCI Thesaurus ValueDomain-2
C29848
UMLS 2011AA ValueDomain-2
C0439234
NCI Thesaurus Property
C17934
UMLS 2011AA Property
C0453996
Not Obtained
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
On the average, about how many cigarettes a day do (or did) you smoke? (1 pack = 20 cigarettes Number of Cigarettes per day)
Description

BaselineSmokeAverageDayValue

Data type

text

Alias
NCI Thesaurus Property
C17934
UMLS 2011AA Property
C0453996
NCI Thesaurus ObjectClass
C18772
UMLS 2011AA ObjectClass
C0262926
NCI Metathesaurus ValueDomain
CL052797
Tobacco Assessment - Section 2
Description

Tobacco Assessment - Section 2

Have you ever smoked this type of tobacco on a regular basis?
Description

ParticipantTobaccoSmokingType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17934
UMLS 2011AA Property
C0453996
Response
Description

TobaccoTypeResponseIndicator

Data type

boolean

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C891
UMLS 2011AA ObjectClass
C0040329
If yes, how many years did you smoke this type of tobacco?
Description

TobaccoTypeYearsSmokedNumber

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ObjectClass
C891
UMLS 2011AA ObjectClass
C0040329
If yes, how many did you usually smoke in a day?
Description

TobaccoTypeSmokingAverageNumber

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ObjectClass
C891
UMLS 2011AA ObjectClass
C0040329
per
Description

ExaminationTimepointType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C68568
UMLS 2011AA Property
C2348792
NCI Thesaurus ValueDomain-2
C68568
UMLS 2011AA ValueDomain-2
C2348792
NCI Thesaurus ObjectClass
C25305
UMLS 2011AA ObjectClass
C0582103
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 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
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Tobacco Use Assessment
    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
Tobacco Assessment
SmokingHistoryLifetimeIndicator
Item
Have you smoked 100 cigarettes or more during your entire lifetime?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
AgeBeganSmokinginYears
Item
Age in years
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property-2)
C0700219 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C29848 (NCI Thesaurus ValueDomain-2)
C0439234 (UMLS 2011AA ValueDomain-2)
C25150 (NCI Thesaurus ValueDomain-3)
C0001779 (UMLS 2011AA ValueDomain-3)
Item
At what age did you begin smoking regularly?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property-2)
C0700219 (UMLS 2011AA Property-2)
CL.2
Code List
At what age did you begin smoking regularly?
CL Item
Don't Know (Don't know)
CL Item
Never Regular (Never regular)
CigaretteUseCurrentStatus
Item
Do you currently smoke cigarettes regularly?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1802 (NCI Thesaurus ObjectClass)
C0677453 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
AgeDiscontinuedSmokinginYears
Item
Age in years
float
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C29848 (NCI Thesaurus ValueDomain-2)
C0439234 (UMLS 2011AA ValueDomain-2)
C25150 (NCI Thesaurus ValueDomain-3)
C0001779 (UMLS 2011AA ValueDomain-3)
Item
At what age did you stop smoking cigarettes on a regular basis?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
CL.4
Code List
At what age did you stop smoking cigarettes on a regular basis?
CL Item
Don't Know (Don't know)
CL Item
Still Smoking (Still smoking)
CigarettesSmokingYearNumber
Item
Years (How many years have you been smoking or did smoke regularly?)
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C1802 (NCI Thesaurus ObjectClass)
C0677453 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain-2)
C0439234 (UMLS 2011AA ValueDomain-2)
C17934 (NCI Thesaurus Property)
C0453996 (UMLS 2011AA Property)
Item
Not Obtained
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
CL310460 (NCI Metathesaurus ObjectClass)
CL052458 (NCI Metathesaurus ObjectClass-2)
C0021212 (NCI Metathesaurus ValueDomain)
CL.5
Code List
Not Obtained
CL Item
Don't Know (Don't Know)
BaselineSmokeAverageDayValue
Item
On the average, about how many cigarettes a day do (or did) you smoke? (1 pack = 20 cigarettes Number of Cigarettes per day)
text
C17934 (NCI Thesaurus Property)
C0453996 (UMLS 2011AA Property)
C18772 (NCI Thesaurus ObjectClass)
C0262926 (UMLS 2011AA ObjectClass)
CL052797 (NCI Metathesaurus ValueDomain)
Item Group
Tobacco Assessment - Section 2
Item
Have you ever smoked this type of tobacco on a regular basis?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17934 (NCI Thesaurus Property)
C0453996 (UMLS 2011AA Property)
CL.6
Code List
Have you ever smoked this type of tobacco on a regular basis?
CL Item
Non-filtered (plain) Cigarettes (Non-filtered (plain) cigarettes)
CL Item
Filtered Cigarettes (Filtered cigarettes)
CL Item
Low Tar Cigarettes (Low tar cigarettes)
CL Item
Pipe (Pipe)
CL Item
Cigar (Cigar)
C1813 (NCI Thesaurus)
C0182504 (UMLS 2011AA)
TobaccoTypeResponseIndicator
Item
Response
boolean
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
TobaccoTypeYearsSmokedNumber
Item
If yes, how many years did you smoke this type of tobacco?
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
TobaccoTypeSmokingAverageNumber
Item
If yes, how many did you usually smoke in a day?
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
Item
per
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C68568 (NCI Thesaurus Property)
C2348792 (UMLS 2011AA Property)
C68568 (NCI Thesaurus ValueDomain-2)
C2348792 (UMLS 2011AA ValueDomain-2)
C25305 (NCI Thesaurus ObjectClass)
C0582103 (UMLS 2011AA ObjectClass)
CL.8
Code List
per
CL Item
Day (day)
C25301 (NCI Thesaurus)
C0439228 (UMLS 2011AA)
CL Item
Week (week)
C29844 (NCI Thesaurus)
C0439230 (UMLS 2011AA)
CL Item
Month (month)
C29846 (NCI Thesaurus)
C0439231 (UMLS 2011AA)
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 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)
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