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1 forms

StudyEvent: Concomitant Medication Form
1. No Instruction available.

Name

Type

Description | Question | Decode (Coded Value)

Data type

Alias

Header

Item Group

Header

RegistrationStep

Item

Registration Step

text

Patient'sName

Item

Patient?s Name

text

ECOGProtocolNo.

Item

ECOG Prot. No.

text

ECOGProtocolNo.

Item

ECOG Prot. No.

text

ECOGPatientID

Item

ECOG Patient Seq. No.

text

ECOGPatientID

Item

ECOG Patient Seq. No.

text

ParticipatingGroupProtocolNo.

Item

Participating Group Prot. No.

text

ParticipatingGroupPatientID

Item

Participating Group Patient ID No.

text

StepNo.

Item

Step No.

text

ParticipatingGroupName

Item

Group

text

InstitutionName

Item

Institution

text

Network

Item

Network

text

AffiliateName

Item

Affiliate

text

Unnamed2

Item Group

Unnamed2

AmendedDataInd

Item

Are data amended? (If yes, please circle amended items in red)

boolean

C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)

IntervalReportFromDate

Item

Reporting period Start Date: (M D Y)

date

IntervalReportToDate

Item

Reporting period End Date: (M D Y)

date

Unnamed3

Item Group

Unnamed3

AgentName

Item

Generic Name (Use brand or trade if generic name unknown)

text

Dose

Item

Dose

float

C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)

Units

Item

Units

text

CL.2

Code List

Units

CL Item

capsules (caps) (capsules (caps))

CL Item

gram (gm) (gram (gm))

CL Item

drops (gtts) (drops (gtts))

CL Item

inch (inch) (inch (inch))

CL Item

kilogram (kg) (kilogram (kg))

CL Item

liter (l) (liter (l))

CL Item

microgram (mcg) (microgram (mcg))

CL Item

milliequivalent (mEq) (milliequivalent (mEq))

CL Item

milligram (mg) (milligram (mg))

CL Item

milliliter (ml) (milliliter (ml))

CL Item

ounce (oz) (ounce (oz))

CL Item

tablets (tabs) (tablets (tabs))

CL Item

tablespoon (tbsp) (tablespoon (tbsp))

CL Item

teaspoon (tsp) (teaspoon (tsp))

CL Item

unit (u) (unit (u))

CL Item

other, specify (other, specify)

other,specify

Item

other, specify

text

C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)

other,specify

Item

other, specify

text

C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)

other,specify

Item

other, specify

text

C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)

Frequency

Item

Frequency

text

C25515 (NCI Thesaurus ObjectClass)
C0439603 (UMLS 2011AA ObjectClass)

CL.3

Code List

Frequency

CL Item

Immediately (stat) (immediately (Stat))

CL Item

As Needed (p.r.n) (as needed (P.R.N))

CL Item

Every Day (q.d.) (every day (Q.D.))

CL Item

Every Other Day (q.o.d.) (every other day (Q.O.D.))

CL Item

Twice A Day (b.i.d) (twice a day (B.I.D))

CL Item

Three Times A Day (t.i.d) (three times a day (T.I.D))

CL Item

Four Times A Day (q.i.d) (four times a day (Q.I.D))

CL Item

Twice A Week (b.i.w) (twice a week (B.I.W))

CL Item

Three Times A Week (t.i.w) (three times a week (T.I.W))

CL Item

Before Meals (a.c.) (before meals (A.C.))

CL Item

After Meals (p.c.) (after meals (P.C.))

CL Item

At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep (H.S.))

CL Item

Every 4 Hours (q4hr) (every 4 hours (Q4hr))

CL Item

Every 6 Hours (q6hr) (every 6 hours (Q6hr))

CL Item

Every 8 Hours (q8hr) (every 8 hours (Q8hr))

CL Item

Every 12 Hours (q12hr) (every 12 hours (Q12hr))

CL Item

Other, Specify (other, specify)

AgentAdminRoute

Item

Route

text

CL.4

Code List

Route

CL Item

Oral Administration Of Drug (oral (p.o.))

CL Item

subcutaneous (s.c.) (subcutaneous (s.c.))

CL Item

Intramuscular Administration Of Drug (intramuscular (i.m.))

CL Item

Intravenous Administration Of Drug (intravenous (i.v.))

CL Item

rectal (rectal)

CL Item

topical (topical)

CL Item

nasal (nasal)

CL Item

inhaled (inhaled)

CL Item

transdermal (transdermal)

CL Item

sublingual (sublingual)

CL Item

intradermal (intradermal)

CL Item

other, specify (other, specify)

AgentBeginDate

Item

Start Date (Leave blank if continuing from a prior report period)

date

Isthismedicationcontinuing?

Item

Is this medication continuing?

boolean

C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)

AgentEndDate

Item

Stop Date (Leave blank if continuing)

date

Unnamed4

Item Group

Unnamed4

Comments

Item

Comments

text

InvestigatorSignature

Item

Investigator Signature

text

C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)

InvestigatorSignatureDate

Item

Date

date

CCRR MODULE

Item Group

Ccrr Module For Concomitant Medication Form

MainMemberInstitution/Affiliate

Item

Institution/Affiliate

text

Patient Initials

Item

Patient Initials

text

C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)

DCIName

Item

DCI Name

text

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