ID

7873

Description

AMC-046 Cidofovir Administration Form (SD6) Cidofovir in Treating HIV-Infected Patients With High-Grade Squamous Intraepithelial Lesions of the Skin Near the Anus Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5353F4EF-C96C-5488-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5353F4EF-C96C-5488-E044-0003BA3F9857

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  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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Anal Cancer NCT00550589 Treatment - AMC-046 Cidofovir Administration Form (SD6) - 2769716v1.0

English

Starting with the office visit day (cycle start, day 1), enter the date and time of application of medication and the date and time for washing off after the medication

1 forms  
Header Module
Description

Header Module

Visit number
Description

Visit number

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1549755
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
Cidofovir Administration
Description

Cidofovir Administration

Day of cycle
Description

AdministeredAgentDayCourseType

Data type

text

Alias
NCI Thesaurus ObjectClass
C41161
UMLS 2011AA ObjectClass
C1521826
NCI Thesaurus ObjectClass-2
C25382
UMLS 2011AA ObjectClass-2
C1521801
NCI Thesaurus Property
C25301
UMLS 2011AA Property
C0439228
NCI Thesaurus Property-2
C25379
UMLS 2011AA Property-2
C0750729
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Agent Start Date (medicine applied mm/dd/yyyy)
Description

Agent Start Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1521826
NCI Thesaurus ValueDomain-2
C25431
UMLS CUI-2
C0808070
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25275
Agent start time (medicine applied hh:mm)
Description

AgentAdministeredBeginTime

Data type

time

Alias
NCI Thesaurus ValueDomain
C25431
UMLS 2011AA ValueDomain
C0439659
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain-2
C25207
UMLS 2011AA ValueDomain-2
C0040223
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Agent End Date (medicine washed off mm/dd/yyyy)
Description

Agent End Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1521826
NCI Thesaurus ObjectClass
C1708
UMLS CUI-2
C0806020
NCI Thesaurus Property
C25275
Agent end time (medicine washed off hh:mm)
Description

AgentAdministeredEndTime

Data type

time

Alias
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain
C25207
UMLS 2011AA ValueDomain
C0040223
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Dose Modification
Description

CidofovirDoseModificationIndicator

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass-2
C1600
UMLS 2011AA ObjectClass-2
C0286078
NCI Thesaurus Property
C25572
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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Similar models

Starting with the office visit day (cycle start, day 1), enter the date and time of application of medication and the date and time for washing off after the medication

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Visit number
Item
Visit number
float
C25337 (NCI Thesaurus ValueDomain)
C1549755 (UMLS CUI-1)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
Item Group
Cidofovir Administration
Item
Day of cycle
text
C41161 (NCI Thesaurus ObjectClass)
C1521826 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus ObjectClass-2)
C1521801 (UMLS 2011AA ObjectClass-2)
C25301 (NCI Thesaurus Property)
C0439228 (UMLS 2011AA Property)
C25379 (NCI Thesaurus Property-2)
C0750729 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.1
Code List
Day of cycle
CL Item
Day 1 (Day 1)
CL Item
Day 2 (Day 2)
CL Item
Day 3 (Day 3)
CL Item
Day 4 (Day 4)
CL Item
Day 5 (Day 5)
Agent Start Date
Item
Agent Start Date (medicine applied mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C1521826 (UMLS CUI-1)
C25431 (NCI Thesaurus ValueDomain-2)
C0808070 (UMLS CUI-2)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
AgentAdministeredBeginTime
Item
Agent start time (medicine applied hh:mm)
time
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25207 (NCI Thesaurus ValueDomain-2)
C0040223 (UMLS 2011AA ValueDomain-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Agent End Date
Item
Agent End Date (medicine washed off mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C0806020 (UMLS CUI-2)
C25275 (NCI Thesaurus Property)
AgentAdministeredEndTime
Item
Agent end time (medicine washed off hh:mm)
time
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Dose Modification
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C1600 (NCI Thesaurus ObjectClass-2)
C0286078 (UMLS 2011AA ObjectClass-2)
C25572 (NCI Thesaurus Property)
CL.2
Code List
Dose Modification
CL Item
No Dose Modification (No dose modifications)
CL Item
Yes, Modification For >= Grade 3 Cutaneous Toxicity (Yes, modification for >= grade 3 cutaneous toxicity)
CL Item
Yes, Modification For Hematologic Or Noncutaneous Nonhematologic Toxicity (Yes, modification for hematologic or noncutaneous nonhematologic toxicity)
CL Item
Yes, Modification For Related >= Grade 2 Metabolic Toxicity (Yes, modification for related >= grade 2 metabolic toxicity)
CL Item
Yes, Modification For Second Occurrence Of Grade 2 Cutaneous Toxicity (Yes, modification for second occurrence of grade 2 cutaneous toxicity)
CL Item
Yes, Non-protocol Defined Modification (Yes, non-protocol defined modification)
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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