ID

8616

Beschrijving

Missed Visit Form - RF35 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=CCE29EA7-C5A3-48CE-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=CCE29EA7-C5A3-48CE-E034-0003BA12F5E7

Trefwoorden

Versies (2)
  1. 20-09-12 20-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Sarcoma, Kaposi xxx On-Study - Missed Visit Form - RF35 - 2266901v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Missed Visit Form - RF35
    1. No Instruction available.
Ccrr Module For Missed Visit Form - Rf35
Beschrijving

Ccrr Module For Missed Visit Form - Rf35

Patient Initials
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Study#
Beschrijving

Protocol ID Coordinating Group

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1711341
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Site#
Beschrijving

NCIInstitutionIdentifierCode

Datatype

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
NCI Thesaurus ObjectClass-2
C19202
UMLS 2011AA ObjectClass-2
C1513882
ID#
Beschrijving

Patient Study ID

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Cycle # Missed
Beschrijving

Cycle Number Chemotherapeutics

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2045829
NCI Thesaurus Property
C25471
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property-2
C25379
Date of Missed Visit
Beschrijving

PatientAbsentVisitDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property-2
C25716
UMLS 2011AA Property-2
C0545082
Reason for missed visit
Beschrijving

PatientAbsentVisitReason

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property-2
C25716
UMLS 2011AA Property-2
C0545082
Other, Specify
Beschrijving

Other,

Datatype

text

Resolution
Beschrijving

Resolution

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Missed Visit Form - RF35
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Ccrr Module For Missed Visit Form - Rf35
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Protocol ID Coordinating Group
Item
Study#
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1711341 (UMLS CUI-2)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
NCIInstitutionIdentifierCode
Item
Site#
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)
C19202 (NCI Thesaurus ObjectClass-2)
C1513882 (UMLS 2011AA ObjectClass-2)
Patient Study ID
Item
ID#
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Cycle Number Chemotherapeutics
Item
Cycle # Missed
text
C25337 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property-2)
PatientAbsentVisitDate
Item
Date of Missed Visit
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property-2)
C0545082 (UMLS 2011AA Property-2)
Item
Reason for missed visit
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property-2)
C0545082 (UMLS 2011AA Property-2)
CL.1
Code List
Reason for missed visit
CL Item
Patient forgot (Patient forgot)
CL Item
Health Reasons (Patient felt too sick to come in)
CL Item
Health Reasons (Patient hospitalized)
CL Item
Patient could not get off work (Patient could not get off work)
CL Item
Patient unable to obtain dependent care (Patient unable to obtain dependent care)
CL Item
Patient had transportation problems (Patient had transportation problems)
CL Item
Patient unhappy with frequency of visits (Patient unhappy with frequency of visits)
CL Item
Scheduling Difficulties (Scheduling conflict)
CL Item
Patient had decided to discontinue study (Patient had decided to discontinue study)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other,
Item
Other, Specify
text
Item
Resolution
text
CL.2
Code List
Resolution
CL Item
Next visit scheduled. Items missed will be made up at the new visit. (Next visit scheduled. Items missed will be made up at the new visit.)
CL Item
Discontinued study (Discontinued study)
CL Item
Adverse event report (fill out RF28). Also fill out NCI form if applicable. (Adverse event report (fill out RF28). Also fill out NCI form if applicable.)
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