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ID

7089

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The Division of Cancer Prevention's agent interruption/modification case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C33C988-5236-20C3-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C33C988-5236-20C3-E044-0003BA3F9857

Nyckelord

Versioner (2)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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    On-Study - Agent Interruption/Modification - 2803972v1.0

    Engelsk

    No Instruction available.

    1 Formulär  
    1. StudyEvent: Agent Interruption/Modification
      1. No Instruction available.
    Screening
    Beskrivning

    Screening

    DCP Protocol #
    Beskrivning

    Protocol ID NCI

    Datatyp

    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
    Beskrivning

    NationalCancerInstituteInstituteCode

    Datatyp

    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
    Beskrivning

    ParticipantIdentifier

    Datatyp

    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
    Beskrivning

    VisitTypeText

    Datatyp

    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
    Beskrivning

    VisitDate

    Datatyp

    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
    Agent Interruption/modification Form
    Beskrivning

    Agent Interruption/modification Form

    Interruption Number
    Beskrivning

    AdditionalAgentInterruptionNumber

    Datatyp

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus ObjectClass-2
    C25406
    UMLS 2011AA ObjectClass-2
    C1524062
    NCI Thesaurus Property
    C25542
    UMLS 2011AA Property
    C1512900
    Specify date stopped (MM/DD/YYYY)
    Beskrivning

    AgentInterruptedDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Metathesaurus Property
    C0723457
    Specify reason stopped
    Beskrivning

    AgentDiscontinuedReasonType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ValueDomain-2
    C25638
    UMLS 2011AA ValueDomain-2
    C0392360
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Metathesaurus Property
    CL212531
    Specify reason stopped
    Beskrivning

    AgentStoppedReasonText

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25484
    UMLS 2011AA Property
    C1444662
    Was agent restarted?
    Beskrivning

    AgentContinuedIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus ObjectClass-2
    C63536
    UMLS 2011AA ObjectClass-2
    C2603343
    NCI Thesaurus Property
    C25180
    UMLS 2011AA Property
    C1522602
    NCI Thesaurus Property-2
    C53279
    UMLS 2011AA Property-2
    C0549178
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If Yes, specify date restarted (MM/DD/YYYY)
    Beskrivning

    AgentContinuedDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus Property
    C25658
    UMLS 2011AA Property
    C1514902
    Specify reason restarted
    Beskrivning

    AgentRestartedReasonType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ValueDomain-2
    C25638
    UMLS 2011AA ValueDomain-2
    C0392360
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus Property
    C25658
    UMLS 2011AA Property
    C1514902
    Agent Modifications
    Beskrivning

    Agent Modifications

    Modification Number
    Beskrivning

    AgentInterruptedModificationorAdjustmentNumber

    Datatyp

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Metathesaurus Property
    CL212531
    NCI Thesaurus ValueDomain-2
    C53606
    UMLS 2011AA ValueDomain-2
    C1709057
    Specify Date Modified
    Beskrivning

    AgentModifiedDate

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C25446
    UMLS 2011AA ObjectClass
    C0392747
    NCI Metathesaurus ObjectClass
    CL076374
    NCI Thesaurus Property
    C25164
    UMLS 2011AA Property
    C0011008
    NCI Metathesaurus Property
    CL219258
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Specify new regimen dose
    Beskrivning

    ModifiedDoseAmount

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C25446
    UMLS 2011AA ObjectClass
    C0392747
    NCI Thesaurus ObjectClass-2
    C25488
    UMLS 2011AA ObjectClass-2
    C0178602
    NCI Thesaurus Property
    C25417
    NCI Thesaurus ValueDomain
    C25417
    Specify new regimen units
    Beskrivning

    AgentModifiedUnits

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C25488
    UMLS 2011AA ObjectClass
    C0178602
    NCI Thesaurus Property
    C25709
    UMLS 2011AA Property
    C1519795
    Specify new regimen frequency
    Beskrivning

    AgentModifiedFrequency

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus Property
    C25488
    UMLS 2011AA Property
    C0178602
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    Dcp Template Footer
    Beskrivning

    Dcp Template Footer

    Protocol Title
    Beskrivning

    Protocol Title

    Datatyp

    text

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

    Protocol Version

    Datatyp

    text

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

    Protocol Version Date

    Datatyp

    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 #
    Beskrivning

    PageNumber

    Datatyp

    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
    Beskrivning

    CaseReportFormTotalPageNumber

    Datatyp

    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
    Beskrivning

    DCPTemplateVersionText

    Datatyp

    text

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

    Similar models

    No Instruction available.

    1 Formulär
    1. StudyEvent: Agent Interruption/Modification
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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
    Agent Interruption/modification Form
    AdditionalAgentInterruptionNumber
    Item
    Interruption Number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C25406 (NCI Thesaurus ObjectClass-2)
    C1524062 (UMLS 2011AA ObjectClass-2)
    C25542 (NCI Thesaurus Property)
    C1512900 (UMLS 2011AA Property)
    AgentInterruptedDate
    Item
    Specify date stopped (MM/DD/YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C0723457 (NCI Metathesaurus Property)
    Item
    Specify reason stopped
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25638 (NCI Thesaurus ValueDomain-2)
    C0392360 (UMLS 2011AA ValueDomain-2)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    CL212531 (NCI Metathesaurus Property)
    CL.1
    Code List
    Specify reason stopped
    CL Item
    Investigator Decision, Specify (Investigator decision, specify)
    CL Item
    Participant Decision, Specify (Participant decision, specify)
    CL Item
    Ae/sae, Specify (AE/SAE, specify)
    CL Item
    Other, Specify (Other, specify)
    AgentStoppedReasonText
    Item
    Specify reason stopped
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus ObjectClass)
    C25484 (NCI Thesaurus Property)
    C1444662 (UMLS 2011AA Property)
    Item
    Was agent restarted?
    text
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C63536 (NCI Thesaurus ObjectClass-2)
    C2603343 (UMLS 2011AA ObjectClass-2)
    C25180 (NCI Thesaurus Property)
    C1522602 (UMLS 2011AA Property)
    C53279 (NCI Thesaurus Property-2)
    C0549178 (UMLS 2011AA Property-2)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Was agent restarted?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Not Applicable (N/A)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    AgentContinuedDate
    Item
    If Yes, specify date restarted (MM/DD/YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C25658 (NCI Thesaurus Property)
    C1514902 (UMLS 2011AA Property)
    Item
    Specify reason restarted
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25638 (NCI Thesaurus ValueDomain-2)
    C0392360 (UMLS 2011AA ValueDomain-2)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C25658 (NCI Thesaurus Property)
    C1514902 (UMLS 2011AA Property)
    CL.3
    Code List
    Specify reason restarted
    CL Item
    Investigator Decision (Investigator decision)
    CL Item
    Participant Decision (Participant decision)
    Item Group
    Agent Modifications
    AgentInterruptedModificationorAdjustmentNumber
    Item
    Modification Number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    CL212531 (NCI Metathesaurus Property)
    C53606 (NCI Thesaurus ValueDomain-2)
    C1709057 (UMLS 2011AA ValueDomain-2)
    AgentModifiedDate
    Item
    Specify Date Modified
    date
    C25446 (NCI Thesaurus ObjectClass)
    C0392747 (UMLS 2011AA ObjectClass)
    CL076374 (NCI Metathesaurus ObjectClass)
    C25164 (NCI Thesaurus Property)
    C0011008 (UMLS 2011AA Property)
    CL219258 (NCI Metathesaurus Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    ModifiedDoseAmount
    Item
    Specify new regimen dose
    float
    C25446 (NCI Thesaurus ObjectClass)
    C0392747 (UMLS 2011AA ObjectClass)
    C25488 (NCI Thesaurus ObjectClass-2)
    C0178602 (UMLS 2011AA ObjectClass-2)
    C25417 (NCI Thesaurus Property)
    C25417 (NCI Thesaurus ValueDomain)
    AgentModifiedUnits
    Item
    Specify new regimen units
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25488 (NCI Thesaurus ObjectClass)
    C0178602 (UMLS 2011AA ObjectClass)
    C25709 (NCI Thesaurus Property)
    C1519795 (UMLS 2011AA Property)
    AgentModifiedFrequency
    Item
    Specify new regimen frequency
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25488 (NCI Thesaurus Property)
    C0178602 (UMLS 2011AA Property)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    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)
    Tillbaka till toppen 

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