ID

9095

Beschreibung

Eligibility form for C3D 3.12 Adopters Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0175F239-AE1E-6771-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0175F239-AE1E-6771-E044-0003BA3F9857

Stichworte

Versionen (3)
  1. 27.08.12 27.08.12 -
  2. 08.01.15 08.01.15 - Martin Dugas
  3. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

9. Januar 2015

DOI

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Eligibility - ELIGIBILITY CHECKLIST - 2411490v1.0

Englisch

Dates will appear as 'DD-MON-YYYY'

1 Formulare  
  1. StudyEvent: ELIGIBILITY CHECKLIST
    1. Dates will appear as 'DD-MON-YYYY'
Eligibility
Beschreibung

Eligibility

Checklist Number
Beschreibung

ChecklistNumber

Datentyp

text

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16112
UMLS 2011AA ObjectClass
C1516637
NCI Thesaurus ValueDomain-2
C49073
UMLS 2011AA ValueDomain-2
C1707357
Effective Date
Beschreibung

EffectiveDate

Datentyp

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Metathesaurus ObjectClass
CL067459
Waiver Number
Beschreibung

WaiverNumber

Datentyp

text

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ObjectClass
C42580
UMLS 2011AA ObjectClass
C1707901
Question Display Sequence
Beschreibung

QuestionDisplaySequence

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C21153
UMLS 2011AA ObjectClass
C1516588
NCI Thesaurus Property
C25673
UMLS 2011AA Property
C1519249
NCI Thesaurus Property-2
C25485
UMLS 2011AA Property-2
C0870432
Eligibility Criteria Text
Beschreibung

EligibilityCriteriaText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25171
UMLS 2011AA ObjectClass
C0013893
NCI Thesaurus Property
C25466
UMLS 2011AA Property
C0243161
Eligibility Criteria Indicator
Beschreibung

EligibilityCriteriaIndicator

Datentyp

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C25171
UMLS 2011AA ObjectClass
C0013893
NCI Thesaurus ObjectClass-2
C71104
UMLS 2011AA ObjectClass-2
C0008976
Eligibility (exclusion)
Beschreibung

Eligibility (exclusion)

Question Display Sequence
Beschreibung

QuestionDisplaySequence

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C21153
UMLS 2011AA ObjectClass
C1516588
NCI Thesaurus Property
C25673
UMLS 2011AA Property
C1519249
NCI Thesaurus Property-2
C25485
UMLS 2011AA Property-2
C0870432
Patient Eligibility Indicator
Beschreibung

Eligibility for trial

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1302261
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25171
Eligibility Criteria Text
Beschreibung

EligibilityCriteriaText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25171
UMLS 2011AA ObjectClass
C0013893
NCI Thesaurus Property
C25466
UMLS 2011AA Property
C0243161
Eligibility Waiver Reason
Beschreibung

EligibilityWaiverReason

Datentyp

text

Alias
NCI Thesaurus Property
C25638
UMLS 2011AA Property
C0392360
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C42580
UMLS 2011AA ObjectClass
C1707901
NCI Thesaurus ValueDomain-2
C42580
UMLS 2011AA ValueDomain-2
C1707901
Eligibility Criteria Indicator
Beschreibung

EligibilityCriteriaIndicator

Datentyp

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C25171
UMLS 2011AA ObjectClass
C0013893
NCI Thesaurus ObjectClass-2
C71104
UMLS 2011AA ObjectClass-2
C0008976
Comments
Beschreibung

Comments

Note Date
Beschreibung

NoteDate

Datentyp

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Metathesaurus ObjectClass
C1317574
Research Comments Text
Beschreibung

Research Comments

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Header Module
Beschreibung

Header Module

NCCTG Study No.
Beschreibung

Protocol ID NCCTG

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1518419
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25581
Central Lab ID Number
Beschreibung

PathologyCoreFacilityLaboratoryIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C37984
UMLS 2011AA ObjectClass
C0022877
NCI Thesaurus ObjectClass-2
C18189
UMLS 2011AA ObjectClass-2
C0030664
NCI Thesaurus ObjectClass-3
C15896
UMLS 2011AA ObjectClass-3
C1511521
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Initials
Beschreibung

Patient Initials

Datentyp

text

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

Institution Number

Datentyp

text

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

Institution Name

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
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Ähnliche Modelle

Dates will appear as 'DD-MON-YYYY'

1 Formulare
  1. StudyEvent: ELIGIBILITY CHECKLIST
    1. Dates will appear as 'DD-MON-YYYY'
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Eligibility
ChecklistNumber
Item
Checklist Number
text
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16112 (NCI Thesaurus ObjectClass)
C1516637 (UMLS 2011AA ObjectClass)
C49073 (NCI Thesaurus ValueDomain-2)
C1707357 (UMLS 2011AA ValueDomain-2)
EffectiveDate
Item
Effective Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CL067459 (NCI Metathesaurus ObjectClass)
WaiverNumber
Item
Waiver Number
text
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C42580 (NCI Thesaurus ObjectClass)
C1707901 (UMLS 2011AA ObjectClass)
QuestionDisplaySequence
Item
Question Display Sequence
text
C21153 (NCI Thesaurus ObjectClass)
C1516588 (UMLS 2011AA ObjectClass)
C25673 (NCI Thesaurus Property)
C1519249 (UMLS 2011AA Property)
C25485 (NCI Thesaurus Property-2)
C0870432 (UMLS 2011AA Property-2)
EligibilityCriteriaText
Item
Eligibility Criteria Text
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C25466 (NCI Thesaurus Property)
C0243161 (UMLS 2011AA Property)
Item
Eligibility Criteria Indicator
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C71104 (NCI Thesaurus ObjectClass-2)
C0008976 (UMLS 2011AA ObjectClass-2)
CL.2
Code List
Eligibility Criteria Indicator
CL Item
Not Applicable (N/A)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Eligibility (exclusion)
QuestionDisplaySequence
Item
Question Display Sequence
text
C21153 (NCI Thesaurus ObjectClass)
C1516588 (UMLS 2011AA ObjectClass)
C25673 (NCI Thesaurus Property)
C1519249 (UMLS 2011AA Property)
C25485 (NCI Thesaurus Property-2)
C0870432 (UMLS 2011AA Property-2)
Item
Patient Eligibility Indicator
text
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
CL.3
Code List
Patient Eligibility Indicator
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
EligibilityCriteriaText
Item
Eligibility Criteria Text
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C25466 (NCI Thesaurus Property)
C0243161 (UMLS 2011AA Property)
EligibilityWaiverReason
Item
Eligibility Waiver Reason
text
C25638 (NCI Thesaurus Property)
C0392360 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C42580 (NCI Thesaurus ObjectClass)
C1707901 (UMLS 2011AA ObjectClass)
C42580 (NCI Thesaurus ValueDomain-2)
C1707901 (UMLS 2011AA ValueDomain-2)
Item
Eligibility Criteria Indicator
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C71104 (NCI Thesaurus ObjectClass-2)
C0008976 (UMLS 2011AA ObjectClass-2)
CL.2
Code List
Eligibility Criteria Indicator
CL Item
Not Applicable (N/A)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Comments
NoteDate
Item
Note Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C1317574 (NCI Metathesaurus ObjectClass)
Research Comments
Item
Research Comments Text
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item Group
Header Module
Protocol ID NCCTG
Item
NCCTG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1518419 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25581 (NCI Thesaurus Property-2)
PathologyCoreFacilityLaboratoryIdentifierNumber
Item
Central Lab ID Number
text
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C18189 (NCI Thesaurus ObjectClass-2)
C0030664 (UMLS 2011AA ObjectClass-2)
C15896 (NCI Thesaurus ObjectClass-3)
C1511521 (UMLS 2011AA ObjectClass-3)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient Initials
Item
Patient Initials
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)
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