ID

7565

Description

AMC-063 Concomitant Medication Form (MED) Bortezomib in Treating Patients With Relapsed or Refractory AIDS-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=815F9798-9FA1-E20D-E040-BB89AD435094

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=815F9798-9FA1-E20D-E040-BB89AD435094

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 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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Sarcoma NCT01016730 Treatment - AMC-063 Concomitant Medication Form (MED) - 3020125v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-063 Concomitant Medication Form (MED)
    1. No Instruction available.
Ccrr Module For Concomitant Antiretroviral Medications - Rf08
Description

Ccrr Module For Concomitant Antiretroviral Medications - Rf08

Agent Name
Description

Agent

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS CUI-1
C1521826
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
Dose Level Start Date
Description

AgentDoseLevelBeginDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25488
UMLS 2011AA Property
C0178602
NCI Thesaurus Property-2
C25554
UMLS 2011AA Property-2
C0441889
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25431
UMLS 2011AA ValueDomain-2
C0439659
Total Daily Dose of Agent (or Drug)
Description

Concomitant Medication Daily Dose

Data type

float

Alias
NCI Thesaurus ObjectClass
C25473
UMLS CUI-1
C2826638
NCI Thesaurus ObjectClass-2
C1708
NCI Thesaurus Property
C25304
NCI Thesaurus Property-2
C25256
NCI Thesaurus ValueDomain
C25488
NCI Thesaurus ValueDomain-2
C1708
Units
Description

AgentConcomitantAdministrationUOM

Data type

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25730
UMLS 2011AA Property
C0521115
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
NCI Thesaurus ValueDomain
C25709
UMLS 2011AA ValueDomain
C1519795
Other, specify
Description

AgentConcomitantAdministrationSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25730
UMLS 2011AA Property
C0521115
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
Frequency
Description

Medication frequency

Data type

text

Alias
NCI Thesaurus ObjectClass
C1708
UMLS CUI-1
C3476109
NCI Thesaurus ValueDomain
C25515
NCI Thesaurus Property
C25382
Other, specify
Description

Medication frequency

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C3476109
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ObjectClass-2
C25409
NCI Thesaurus Property
C25275
Is this an antiretroviral agent
Description

Anti-RetroviralAgentsAdministeredInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Metathesaurus ObjectClass
C0599685
Please provide indication (If "no")
Description

Anti-RetroviralAgentsNotAdministeredReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
NCI Metathesaurus ObjectClass
C0599685
Is use of this agent ongoing
Description

ConcomitantMedicationAdministrationCurrentInd-3

Data type

boolean

Alias
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
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ValueDomain-2
C25471
UMLS 2011AA ValueDomain-2
C0521116
Date last taken (If "no" mm/dd/yyyy)
Description

ConcomitantMedicationAdministrationLastDate

Data type

date

Alias
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
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25551
UMLS 2011AA ValueDomain-2
C1517741
Comments
Description

Comments

Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
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1 forms
  1. StudyEvent: AMC-063 Concomitant Medication Form (MED)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Concomitant Antiretroviral Medications - Rf08
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)
AgentDoseLevelBeginDate
Item
Dose Level Start Date
date
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25488 (NCI Thesaurus Property)
C0178602 (UMLS 2011AA Property)
C25554 (NCI Thesaurus Property-2)
C0441889 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0439659 (UMLS 2011AA ValueDomain-2)
Concomitant Medication Daily Dose
Item
Total Daily Dose of Agent (or Drug)
float
C25473 (NCI Thesaurus ObjectClass)
C2826638 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass-2)
C25304 (NCI Thesaurus Property)
C25256 (NCI Thesaurus Property-2)
C25488 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ValueDomain-2)
Item
Units
text
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus Property)
C0521115 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25709 (NCI Thesaurus ValueDomain)
C1519795 (UMLS 2011AA ValueDomain)
CL.1
Code List
Units
CL Item
Milligram (Milligram)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
CL Item
Microgram (Microgram)
CL Item
Milliliter (Milliliter)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Unit (Unit)
C44278 (NCI Thesaurus)
C0439148 (UMLS 2011AA)
CL Item
International Unit (International Unit)
C28255 (NCI Thesaurus)
CL Item
Capsules (Capsules)
CL Item
Tablets (Tablets)
CL Item
Drops (Drops)
C69442 (NCI Thesaurus)
C2347093 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AgentConcomitantAdministrationSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus Property)
C0521115 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
Item
Frequency
text
C1708 (NCI Thesaurus ObjectClass)
C3476109 (UMLS CUI-1)
C25515 (NCI Thesaurus ValueDomain)
C25382 (NCI Thesaurus Property)
CL.2
Code List
Frequency
CL Item
Once A Day (q.d.) (Once a day (Q.D.))
CL Item
Twice A Day (b.i.d) (twice a day (B.I.D))
CL Item
Three Times A Day (t.i.d) (three times a day (T.I.D))
CL Item
Four Times A Day (q.i.d) (four times a day (Q.I.D))
CL Item
>4x/day (>4X/day)
CL Item
Every 4 Hours (q4hr) (every 4 hours (Q4hr))
CL Item
Every 6 Hours (q6hr) (every 6 hours (Q6hr))
CL Item
Every 8 Hours (q8hr) (every 8 hours (Q8hr))
CL Item
Every 12 Hours (q12hr) (every 12 hours (Q12hr))
CL Item
At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep (H.S.))
CL Item
Every Other Day (q.o.d.) (every other day (Q.O.D.))
CL Item
Weekly (Weekly)
CL158132 (NCI Metathesaurus)
CL Item
Monthly (Monthly)
CL Item
As Needed (p.r.n) (as needed (P.R.N))
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Medication frequency
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C3476109 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C25409 (NCI Thesaurus ObjectClass-2)
C25275 (NCI Thesaurus Property)
Anti-RetroviralAgentsAdministeredInd-2
Item
Is this an antiretroviral agent
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0599685 (NCI Metathesaurus ObjectClass)
Anti-RetroviralAgentsNotAdministeredReason
Item
Please provide indication (If "no")
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C0599685 (NCI Metathesaurus ObjectClass)
ConcomitantMedicationAdministrationCurrentInd-3
Item
Is use of this agent ongoing
boolean
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)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ValueDomain-2)
C0521116 (UMLS 2011AA ValueDomain-2)
ConcomitantMedicationAdministrationLastDate
Item
Date last taken (If "no" mm/dd/yyyy)
date
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)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)
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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