ID

7637

Description

ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form Surgery With or Without Internal Radiation Therapy Compared With Stereotactic Body Radiation Therapy in Treating Patients With High-Risk Stage I Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=98F2A8AC-D8D1-9DE5-E040-BB89AD434043

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=98F2A8AC-D8D1-9DE5-E040-BB89AD434043

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

9 janvier 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT01336894 On-Study - ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form - 3179637v1.0

Anglais

ALL ITEMS MUST BE COMPLETED

1 Formulaires  
  1. StudyEvent: ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form
    1. ALL ITEMS MUST BE COMPLETED
Header Module
Description

Header Module

Protocol Number
Description

Protocol ID ACOSOG

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1515944
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C19712
Patient ID
Description

Patient Study ID

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Patient Initials (L F M)
Description

Patient Initials

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Institution Number
Description

Institution Number

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Institution
Description

Institution Name

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Are data amended (check one if data amended, please circle in red when using paper forms)
Description

Data amended

Type de données

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Visit
Description

Visit

Visit (after registration and before SBRT or surgery)
Description

AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C19712
UMLS 2011AA ObjectClass
C1515944
NCI Thesaurus ObjectClass-2
C25716
UMLS 2011AA ObjectClass-2
C0545082
Comorbid Conditions
Description

Comorbid Conditions

Comorbidity (check one)
Description

ConcomitantDiseasePersonalMedicalHistoryType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass-2
C25730
UMLS 2011AA ObjectClass-2
C0521115
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Present (check one)
Description

ChronicDiseasePresentInd-3

Type de données

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass-2
C14141
UMLS 2011AA ObjectClass-2
C0205191
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Similar models

ALL ITEMS MUST BE COMPLETED

1 Formulaires
  1. StudyEvent: ACOSOG-Z4099 Charlson Comorbidity Index (CCI) Scoring Sheet Form
    1. ALL ITEMS MUST BE COMPLETED
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Header Module
Protocol ID ACOSOG
Item
Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1515944 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C19712 (NCI Thesaurus Property-2)
Patient Study ID
Item
Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Patient Initials
Item
Patient Initials (L F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Institution Number
Item
Institution Number
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Institution Name
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Data amended
Item
Are data amended (check one if data amended, please circle in red when using paper forms)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Visit
Item
Visit (after registration and before SBRT or surgery)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19712 (NCI Thesaurus ObjectClass)
C1515944 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus ObjectClass-2)
C0545082 (UMLS 2011AA ObjectClass-2)
CL.2
Code List
Visit (after registration and before SBRT or surgery)
CL Item
Registration (Registration)
C25646 (NCI Thesaurus)
C1514821 (UMLS 2011AA)
Item Group
Comorbid Conditions
Item
Comorbidity (check one)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
CL.3
Code List
Comorbidity (check one)
CL Item
Myocardial Infarction (Myocardial infarction)
C27996 (NCI Thesaurus)
C0027051 (UMLS 2011AA)
CL Item
Congestive Heart Failure (Congestive heart failure)
C3080 (NCI Thesaurus)
C0018802 (UMLS 2011AA)
CL Item
Peripheral Vascular Disease (Peripheral vascular disease)
CL Item
Cerebrovascular Disease (Cerebrovascular disease)
CL Item
Dementia (Dementia)
CL Item
Chronic Pulmonary Disease (Chronic pulmonary disease)
CL Item
Connective Tissue Disease (Connective tissue disease)
CL Item
Ulcer (Ulcer disease)
C3426 (NCI Thesaurus)
C0041582 (UMLS 2011AA)
CL Item
Mild Liver Disease (Mild liver disease)
CL Item
Diabetes (Diabetes)
CL Item
Diabetes Complication (Diabetes with end organ damage)
C84415 (NCI Thesaurus)
C0342257 (UMLS 2011AA)
CL Item
Hemiplegia (Hemiplegia)
CL Item
Renal Disorder (Moderate or severe renal disease)
C3149 (NCI Thesaurus)
C0022658 (UMLS 2011AA)
CL Item
Second Solid Tumor (Second Solid tumor)
CL Item
Leukemia (Leukemia)
C3161 (NCI Thesaurus)
C0023418 (UMLS 2011AA)
CL Item
Lymphoma, Multiple Myeloma, Nhl, Hodgkin's, Waldenstrom (Lymphoma, Multiple Myeloma, NHL, Hodgkin's, Waldenstrom)
CL Item
Liver And Biliary Tract Disorder (Moderate or severe liver disease)
C3959 (NCI Thesaurus)
C0267792 (UMLS 2011AA)
CL Item
Second Metastatic Solid Tumor (Second Metastatic solid tumor)
CL Item
Aids (AIDS)
ChronicDiseasePresentInd-3
Item
Present (check one)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)
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