ID

7467

Descrizione

AMC-052 On Study Form (F02) Human Papillomavirus Vaccine Therapy in Treating Men With HIV-1 Infection Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3952E724-40D1-361E-E044-0003BA3F9857

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3952E724-40D1-361E-E044-0003BA3F9857

Keywords

versioni (2)
  1. 19/09/12 19/09/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Infection NCT00513526 On-Study - AMC-052 On Study Form (F02) - 2676644v1.0

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: AMC-052 On Study Form (F02)
    1. No Instruction available.
Header
Descrizione

Header

Visit number
Descrizione

Visit number

Tipo di dati

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1549755
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
Hiv History
Descrizione

Hiv History

Date of HIV+ diagnosis
Descrizione

HumanImmunodeficiencyVirusDiagnosisDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C14219
UMLS 2011AA ObjectClass
C0019682
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Date of AIDS diagnosis
Descrizione

AcquiredImmunodeficiencySyndromeDiagnosisDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ObjectClass
C2851
UMLS 2011AA ObjectClass
C0001175
CDC HIV Risk Group
Descrizione

PatientHumanImmunodeficiencyVirusRiskCategory

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C14219
UMLS 2011AA Property
C0019682
NCI Thesaurus Property-2
C17102
UMLS 2011AA Property-2
C0035647
NCI Thesaurus Property-3
C25161
UMLS 2011AA Property-3
C0008902
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
Other, specify
Descrizione

PatientHumanImmunodeficiencyVirusRiskCategorySpecify

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C14219
UMLS 2011AA Property
C0019682
NCI Thesaurus Property-2
C17102
UMLS 2011AA Property-2
C0035647
NCI Thesaurus Property-3
C25161
UMLS 2011AA Property-3
C0008902
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Ccrr Module For On Study Form - Rf02b
Descrizione

Ccrr Module For On Study Form - Rf02b

Date of Initial Pathologic Diagnosis
Descrizione

CancerInitialDiagnosisDate

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property-2
C15220
UMLS 2011AA Property-2
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
Primary site
Descrizione

AcquiredImmunodeficiencySyndromeMalignantNeoplasmPrimarySite

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ObjectClass-2
C2851
UMLS 2011AA ObjectClass-2
C0001175
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25251
UMLS 2011AA Property-2
C0205225
NCI Thesaurus ValueDomain
C37901
UMLS 2011AA ValueDomain
C0205145
Other specify
Descrizione

MalignantNeoplasmPrimarySiteSpecify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25251
UMLS 2011AA Property-2
C0205225
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
Specify tumor histologic category
Descrizione

DominantTumorHistologicCategorySpecify

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass-2
C25487
UMLS 2011AA ObjectClass-2
C1527180
NCI Thesaurus Property
C25526
UMLS 2011AA Property
C0205462
NCI Thesaurus Property-2
C25161
UMLS 2011AA Property-2
C0008902
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Ccrr Module For On Study Form - Rf02b
Descrizione

Ccrr Module For On Study Form - Rf02b

History of Prior Malignancy
Descrizione

PatientPriorMalignantNeoplasmHistoryInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C25629
UMLS 2011AA ObjectClass-2
C0332152
NCI Thesaurus Property
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property-2
C25629
UMLS 2011AA Property-2
C0332152
NCI Thesaurus Property-3
C18772
UMLS 2011AA Property-3
C0262926
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Date of Diagnosis of Previous Malignancy
Descrizione

PriorCancerDiagnosisDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ObjectClass-2
C25629
UMLS 2011AA ObjectClass-2
C0332152
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Primary site
Descrizione

AcquiredImmunodeficiencySyndromeMalignantNeoplasmPrimarySite

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ObjectClass-2
C2851
UMLS 2011AA ObjectClass-2
C0001175
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25251
UMLS 2011AA Property-2
C0205225
NCI Thesaurus ValueDomain
C37901
UMLS 2011AA ValueDomain
C0205145
Other specify
Descrizione

MalignantNeoplasmPrimarySiteSpecify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25251
UMLS 2011AA Property-2
C0205225
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
Specify tumor histologic category
Descrizione

DominantTumorHistologicCategorySpecify

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass-2
C25487
UMLS 2011AA ObjectClass-2
C1527180
NCI Thesaurus Property
C25526
UMLS 2011AA Property
C0205462
NCI Thesaurus Property-2
C25161
UMLS 2011AA Property-2
C0008902
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Antiretroviral Therapy
Descrizione

Antiretroviral Therapy

Agent Name
Descrizione

Agent

Tipo di dati

text

Alias
NCI Thesaurus Property
C25364
UMLS CUI-1
C1521826
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
Other, specify
Descrizione

Anti-RetroviralAgentsAdministeredSpecify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain-2
C25382
UMLS 2011AA ValueDomain-2
C1521801
NCI Metathesaurus ObjectClass
C0599685
Agent use
Descrizione

Anti-RetroviralAgentsAdministeredStatus

Tipo di dati

text

Alias
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Metathesaurus ObjectClass
C0599685
Duration if prior agents received
Descrizione

Anti-RetroviralAgentsDurationAdministeredType

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Metathesaurus ObjectClass
C0599685
NCI Thesaurus Property-2
C25330
UMLS 2011AA Property-2
C0449238
Comments
Descrizione

Comments

Comments
Descrizione

Research Comments

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: AMC-052 On Study Form (F02)
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Header
Visit number
Item
Visit number
float
C25337 (NCI Thesaurus ValueDomain)
C1549755 (UMLS CUI-1)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
Item Group
Hiv History
HumanImmunodeficiencyVirusDiagnosisDate
Item
Date of HIV+ diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C14219 (NCI Thesaurus ObjectClass)
C0019682 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
AcquiredImmunodeficiencySyndromeDiagnosisDate
Item
Date of AIDS diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C2851 (NCI Thesaurus ObjectClass)
C0001175 (UMLS 2011AA ObjectClass)
Item
CDC HIV Risk Group
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C14219 (NCI Thesaurus Property)
C0019682 (UMLS 2011AA Property)
C17102 (NCI Thesaurus Property-2)
C0035647 (UMLS 2011AA Property-2)
C25161 (NCI Thesaurus Property-3)
C0008902 (UMLS 2011AA Property-3)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
CL.1
Code List
CDC HIV Risk Group
CL Item
Hemophilia (Hemophiliac)
C3093 (NCI Thesaurus)
C0684275 (UMLS 2011AA)
CL Item
Heterosexual Contact (Heterosexual contact)
CL Item
Homosexual Or Bisexual Contact (Homosexual or bisexual contact)
CL Item
Iv Drug User (IV drug user)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Transfusion Recipient (Transfusion recipient)
PatientHumanImmunodeficiencyVirusRiskCategorySpecify
Item
Other, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C14219 (NCI Thesaurus Property)
C0019682 (UMLS 2011AA Property)
C17102 (NCI Thesaurus Property-2)
C0035647 (UMLS 2011AA Property-2)
C25161 (NCI Thesaurus Property-3)
C0008902 (UMLS 2011AA Property-3)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For On Study Form - Rf02b
CancerInitialDiagnosisDate
Item
Date of Initial Pathologic Diagnosis
date
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Item
Primary site
text
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C2851 (NCI Thesaurus ObjectClass-2)
C0001175 (UMLS 2011AA ObjectClass-2)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
C37901 (NCI Thesaurus ValueDomain)
C0205145 (UMLS 2011AA ValueDomain)
CL.4
Code List
Primary site
CL Item
Anal Canal (Anal)
C12375 (NCI Thesaurus)
C0227411 (UMLS 2011AA)
CL Item
Cervical (Cervical)
C12844 (NCI Thesaurus)
C0205064 (UMLS 2011AA)
CL Item
Hd (HD)
CL Item
Kaposi Sarcoma (KS)
C9087 (NCI Thesaurus)
C0036220 (UMLS 2011AA)
CL Item
Non-hodgkin's Lymphoma (NHL)
C3211 (NCI Thesaurus)
C0024305 (UMLS 2011AA)
CL Item
Other Primary Site (Other primary site)
MalignantNeoplasmPrimarySiteSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
DominantTumorHistologicCategorySpecify
Item
Specify tumor histologic category
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25487 (NCI Thesaurus ObjectClass-2)
C1527180 (UMLS 2011AA ObjectClass-2)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property-2)
C0008902 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For On Study Form - Rf02b
PatientPriorMalignantNeoplasmHistoryInd-2
Item
History of Prior Malignancy
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property-2)
C0332152 (UMLS 2011AA Property-2)
C18772 (NCI Thesaurus Property-3)
C0262926 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PriorCancerDiagnosisDate
Item
Date of Diagnosis of Previous Malignancy
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
Item
Primary site
text
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C2851 (NCI Thesaurus ObjectClass-2)
C0001175 (UMLS 2011AA ObjectClass-2)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
C37901 (NCI Thesaurus ValueDomain)
C0205145 (UMLS 2011AA ValueDomain)
CL.4
Code List
Primary site
CL Item
Anal Canal (Anal)
C12375 (NCI Thesaurus)
C0227411 (UMLS 2011AA)
CL Item
Cervical (Cervical)
C12844 (NCI Thesaurus)
C0205064 (UMLS 2011AA)
CL Item
Hd (HD)
CL Item
Kaposi Sarcoma (KS)
C9087 (NCI Thesaurus)
C0036220 (UMLS 2011AA)
CL Item
Non-hodgkin's Lymphoma (NHL)
C3211 (NCI Thesaurus)
C0024305 (UMLS 2011AA)
CL Item
Other Primary Site (Other primary site)
MalignantNeoplasmPrimarySiteSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
DominantTumorHistologicCategorySpecify
Item
Specify tumor histologic category
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25487 (NCI Thesaurus ObjectClass-2)
C1527180 (UMLS 2011AA ObjectClass-2)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property-2)
C0008902 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Antiretroviral Therapy
Agent
Item
Agent Name
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
Anti-RetroviralAgentsAdministeredSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25382 (NCI Thesaurus ValueDomain-2)
C1521801 (UMLS 2011AA ValueDomain-2)
C0599685 (NCI Metathesaurus ObjectClass)
Item
Agent use
text
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C0599685 (NCI Metathesaurus ObjectClass)
CL.5
Code List
Agent use
CL Item
Currently Receiving (Currently receiving)
CL Item
Never Received (Never received)
CL Item
Previously Received (Previously received)
Item
Duration if prior agents received
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0599685 (NCI Metathesaurus ObjectClass)
C25330 (NCI Thesaurus Property-2)
C0449238 (UMLS 2011AA Property-2)
CL.6
Code List
Duration if prior agents received
CL Item
3-6 Months (3-6 months)
CL Item
< 3 Months (< 3 months)
CL Item
> 12 Months (> 12 months)
CL Item
> 6-12 Months (> 6-12 months)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
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