ID

7095

Descripción

The Division of Cancer Prevention's off study case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=51740570-60A4-7104-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=51740570-60A4-7104-E044-0003BA3F9857

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
Subido en

9 de enero de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Off Treatment - Off Study - 2762907v1.0

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: Off Study
    1. No Instruction available.
Screening
Descripción

Screening

DCP Protocol #
Descripción

Protocol ID NCI

Tipo de datos

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
Descripción

NationalCancerInstituteInstituteCode

Tipo de datos

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
Descripción

ParticipantIdentifier

Tipo de datos

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
Form Date
Descripción

FormCompletionDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
Off Study
Descripción

Off Study

Date on Follow-up
Descripción

OnFollow-UpDate

Tipo de datos

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16033
UMLS 2011AA ObjectClass
C1522577
Date Off Follow-up
Descripción

OffFollow-UpDate

Tipo de datos

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16033
UMLS 2011AA ObjectClass
C1522577
NCI Thesaurus ObjectClass-2
C40450
UMLS 2011AA ObjectClass-2
C1518543
Date Off Study
Descripción

ParticipantOffStudyDate

Tipo de datos

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15206
UMLS 2011AA ObjectClass
C0008972
NCI Thesaurus ObjectClass-2
C40450
UMLS 2011AA ObjectClass-2
C1518543
Date of Last Contact
Descripción

LastContactwithParticipantDate

Tipo de datos

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C47954
UMLS 2011AA ObjectClass
C1705415
NCI Thesaurus ObjectClass-2
C25551
UMLS 2011AA ObjectClass-2
C1517741
Date Last Study Agent Taken
Descripción

LastStudyAgentDate

Tipo de datos

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property-2
C25496
UMLS 2011AA Property-2
C2746065
Not Obtained
Descripción

NotObtainedIndicator

Tipo de datos

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
Descripción

NotObtainedIndicator

Tipo de datos

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
Descripción

NotObtainedIndicator

Tipo de datos

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Metathesaurus ObjectClass
CL310460
NCI Metathesaurus ObjectClass-2
CL052458
NCI Metathesaurus ValueDomain
C0021212
Reason Off Study
Descripción

OffStudyReasonName

Tipo de datos

text

Alias
NCI Thesaurus Property
C25638
UMLS 2011AA Property
C0392360
NCI Thesaurus ObjectClass
C15206
UMLS 2011AA ObjectClass
C0008972
NCI Thesaurus ObjectClass-2
C40450
UMLS 2011AA ObjectClass-2
C1518543
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
Reason
Descripción

OffStudyReasonText

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C15206
UMLS 2011AA ObjectClass
C0008972
NCI Thesaurus ObjectClass-2
C40450
UMLS 2011AA ObjectClass-2
C1518543
NCI Thesaurus Property
C25638
UMLS 2011AA Property
C0392360
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25638
UMLS 2011AA ValueDomain-2
C0392360
NCI Thesaurus ValueDomain-3
C29851
UMLS 2011AA ValueDomain-3
C1518546
Dcp Template Footer
Descripción

Dcp Template Footer

Protocol Title
Descripción

Protocol Title

Tipo de datos

text

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

Protocol Version

Tipo de datos

text

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

Protocol Version Date

Tipo de datos

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 #
Descripción

PageNumber

Tipo de datos

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
Descripción

CaseReportFormTotalPageNumber

Tipo de datos

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
Descripción

DCPTemplateVersionText

Tipo de datos

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 formularios
  1. StudyEvent: Off Study
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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)
FormCompletionDate
Item
Form Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
Item Group
Off Study
OnFollow-UpDate
Item
Date on Follow-up
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16033 (NCI Thesaurus ObjectClass)
C1522577 (UMLS 2011AA ObjectClass)
OffFollow-UpDate
Item
Date Off Follow-up
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16033 (NCI Thesaurus ObjectClass)
C1522577 (UMLS 2011AA ObjectClass)
C40450 (NCI Thesaurus ObjectClass-2)
C1518543 (UMLS 2011AA ObjectClass-2)
ParticipantOffStudyDate
Item
Date Off Study
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15206 (NCI Thesaurus ObjectClass)
C0008972 (UMLS 2011AA ObjectClass)
C40450 (NCI Thesaurus ObjectClass-2)
C1518543 (UMLS 2011AA ObjectClass-2)
LastContactwithParticipantDate
Item
Date of Last Contact
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C47954 (NCI Thesaurus ObjectClass)
C1705415 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
LastStudyAgentDate
Item
Date Last Study Agent Taken
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25496 (NCI Thesaurus Property-2)
C2746065 (UMLS 2011AA Property-2)
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.3
Code List
Not Obtained
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
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.3
Code List
Not Obtained
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
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.3
Code List
Not Obtained
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
Item
Reason Off Study
text
C25638 (NCI Thesaurus Property)
C0392360 (UMLS 2011AA Property)
C15206 (NCI Thesaurus ObjectClass)
C0008972 (UMLS 2011AA ObjectClass)
C40450 (NCI Thesaurus ObjectClass-2)
C1518543 (UMLS 2011AA ObjectClass-2)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
CL.4
Code List
Reason Off Study
CL Item
Completed Study (COMPLETED STUDY)
CL Item
Ineligible (Ineligible)
CL Item
Adverse Event/serious Adverse Event (complete Ae Crf & Sae Form, If Applicable) (AE/SAE)
CL Item
Lost To Follow-up (Lost to follow-up)
CL310949 (NCI Metathesaurus)
CL Item
Non-compliant Participant (Non-compliant participant)
CL Item
Concomitant Medication (Concomitant medication)
CL Item
Medical Contraindication (Medical contraindication)
CL Item
Pregnancy (Pregnancy)
C25742 (NCI Thesaurus)
C0032961 (UMLS 2011AA)
CL Item
Withdraw Consent (Withdraw consent)
CL Item
Death (complete Death Report Crf & Sae Form) (Death)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
OffStudyReasonText
Item
Reason
text
C15206 (NCI Thesaurus ObjectClass)
C0008972 (UMLS 2011AA ObjectClass)
C40450 (NCI Thesaurus ObjectClass-2)
C1518543 (UMLS 2011AA ObjectClass-2)
C25638 (NCI Thesaurus Property)
C0392360 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25638 (NCI Thesaurus ValueDomain-2)
C0392360 (UMLS 2011AA ValueDomain-2)
C29851 (NCI Thesaurus ValueDomain-3)
C1518546 (UMLS 2011AA ValueDomain-3)
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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