ID

9095

Beschrijving

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

Trefwoorden

Versies (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
Geüploaded op

9 januari 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Eligibility - ELIGIBILITY CHECKLIST - 2411490v1.0

Engels

Dates will appear as 'DD-MON-YYYY'

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

Eligibility

Checklist Number
Beschrijving

ChecklistNumber

Datatype

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
Beschrijving

EffectiveDate

Datatype

date

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

WaiverNumber

Datatype

text

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

QuestionDisplaySequence

Datatype

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
Beschrijving

EligibilityCriteriaText

Datatype

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
Beschrijving

EligibilityCriteriaIndicator

Datatype

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)
Beschrijving

Eligibility (exclusion)

Question Display Sequence
Beschrijving

QuestionDisplaySequence

Datatype

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
Beschrijving

Eligibility for trial

Datatype

text

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

EligibilityCriteriaText

Datatype

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
Beschrijving

EligibilityWaiverReason

Datatype

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
Beschrijving

EligibilityCriteriaIndicator

Datatype

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
Beschrijving

Comments

Note Date
Beschrijving

NoteDate

Datatype

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
Beschrijving

Research Comments

Datatype

text

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

Header Module

NCCTG Study No.
Beschrijving

Protocol ID NCCTG

Datatype

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
Beschrijving

PathologyCoreFacilityLaboratoryIdentifierNumber

Datatype

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
Beschrijving

Patient Initials

Datatype

text

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

Institution Number

Datatype

text

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

Institution Name

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Terug naar het begin van de pagina

Similar models

Dates will appear as 'DD-MON-YYYY'

1 Formulieren
  1. StudyEvent: ELIGIBILITY CHECKLIST
    1. Dates will appear as 'DD-MON-YYYY'
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial