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ID

7103

Description

The Division of Cancer Prevention's participant contact case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C23CCAA-6AB8-3B80-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5C23CCAA-6AB8-3B80-E044-0003BA3F9857

Keywords

  1. 9/20/12 9/20/12 -
  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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    On-Study - Participant Contact - 2803817v1.0

    No Instruction available.

    1. StudyEvent: Participant Contact
      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
    Date of last contact within treatment period (MM/DD/YYYY)
    Description

    PatientLastClinicalStudyPeriodContactDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus Property-2
    C25461
    UMLS 2011AA Property-2
    C0337611
    NCI Thesaurus Property-3
    C15206
    UMLS 2011AA Property-3
    C0008972
    NCI Thesaurus Property-4
    C25551
    UMLS 2011AA Property-4
    C1517741
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Participant Contact Form
    Description

    Participant Contact Form

    Contact Type
    Description

    PersonContactType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C19442
    UMLS 2011AA ObjectClass
    C0009458
    Contact Time (hr:mm per 24 hour clock)
    Description

    PersonContactTime

    Data type

    time

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25207
    UMLS 2011AA Property
    C0040223
    NCI Thesaurus ValueDomain
    C25207
    UMLS 2011AA ValueDomain
    C0040223
    NCI Thesaurus Property-2
    C25461
    UMLS 2011AA Property-2
    C0337611
    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
    Contact Result
    Description

    PatientContactTextType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25461
    UMLS 2011AA Property
    C0337611
    Did the participant report any symptoms or adverse events?
    Description

    SymptomorAdverseEventOccurrenceInd

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C41331
    UMLS 2011AA ObjectClass
    C0877248
    NCI Metathesaurus Property
    CL209504
    Were any changes in concomitant medications reported? ([Either new medications started or previous medications stopped]?)
    Description

    ConcomitantMedicationReportedIndicator

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C459
    UMLS 2011AA ObjectClass
    C0013227
    NCI Thesaurus ObjectClass-2
    C25730
    UMLS 2011AA ObjectClass-2
    C0521115
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    Is the participant compliant with protocol intervention per telephone conversation or email?
    Description

    ProtocolComplianceIndicator

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass-2
    C42651
    UMLS 2011AA ObjectClass
    C0442711
    NCI Thesaurus Property
    C25194
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ValueDomain-2
    C25180
    UMLS 2011AA ValueDomain-2
    C1522602
    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

    Similar models

    No Instruction available.

    1. StudyEvent: Participant Contact
      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)
    PatientLastClinicalStudyPeriodContactDate
    Item
    Date of last contact within treatment period (MM/DD/YYYY)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25461 (NCI Thesaurus Property-2)
    C0337611 (UMLS 2011AA Property-2)
    C15206 (NCI Thesaurus Property-3)
    C0008972 (UMLS 2011AA Property-3)
    C25551 (NCI Thesaurus Property-4)
    C1517741 (UMLS 2011AA Property-4)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item Group
    Participant Contact Form
    Item
    Contact Type
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C19442 (NCI Thesaurus ObjectClass)
    C0009458 (UMLS 2011AA ObjectClass)
    Code List
    Contact Type
    CL Item
    Home Phone Number (Home phone)
    CL Item
    Work Phone (Work phone)
    CL Item
    Home Cell (Home Cell)
    CL Item
    Work Cell (Work Cell)
    CL Item
    Contact By Email (Email)
    CL Item
    Work Email (Work email)
    CL Item
    Contact By Regular Mail (Regular Mail)
    PersonContactTime
    Item
    Contact Time (hr:mm per 24 hour clock)
    time
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25207 (NCI Thesaurus Property)
    C0040223 (UMLS 2011AA Property)
    C25207 (NCI Thesaurus ValueDomain)
    C0040223 (UMLS 2011AA ValueDomain)
    C25461 (NCI Thesaurus Property-2)
    C0337611 (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)
    Code List
    Not Obtained
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    C17998 (NCI Thesaurus-3)
    C0439673 (UMLS 2011AA-4)
    Item
    Contact Result
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25461 (NCI Thesaurus Property)
    C0337611 (UMLS 2011AA Property)
    Code List
    Contact Result
    CL Item
    Spoke To Patient/participant (Spoke to Patient/Participant)
    CL Item
    Spoke To Family Member (Spoke to family member)
    CL Item
    Spoke To Friend (Spoke to friend)
    CL Item
    Left Voicemail Message (Left voicemail message)
    CL Item
    Email Contact With Patient/participant (Email contact with Patient/Participant)
    CL Item
    Mail Contact With Patient/participant (Mail contact with Patient/Participant)
    CL Item
    No Contact Made (No contact made)
    Item
    Did the participant report any symptoms or adverse events?
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus ObjectClass)
    C0877248 (UMLS 2011AA ObjectClass)
    CL209504 (NCI Metathesaurus Property)
    Code List
    Did the participant report any symptoms or adverse events?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Too Early To Evaluate (Too early to evaluate)
    Item
    Were any changes in concomitant medications reported? ([Either new medications started or previous medications stopped]?)
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C459 (NCI Thesaurus ObjectClass)
    C0013227 (UMLS 2011AA ObjectClass)
    C25730 (NCI Thesaurus ObjectClass-2)
    C0521115 (UMLS 2011AA ObjectClass-2)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    Code List
    Were any changes in concomitant medications reported? ([Either new medications started or previous medications stopped]?)
    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)
    Item
    Is the participant compliant with protocol intervention per telephone conversation or email?
    text
    C15368 (NCI Thesaurus ObjectClass)
    C42651 (NCI Thesaurus ObjectClass-2)
    C0442711 (UMLS 2011AA ObjectClass)
    C25194 (NCI Thesaurus Property)
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25180 (NCI Thesaurus ValueDomain-2)
    C1522602 (UMLS 2011AA ValueDomain-2)
    Code List
    Is the participant compliant with protocol intervention per telephone conversation or email?
    CL Item
    Yes (YES)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (NO)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (UNKNOWN)
    C17998 (NCI Thesaurus)
    C0439673 (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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