ID

9838

Description

AMC-053 Enrollment Form (ENR) Bortezomib, Ifosfamide, Carboplatin, and Etoposide, With or Without Rituximab, in Treating Patients With Relapsed or Refractory AIDS-Related Non-Hodgkin Lymphoma NCT00598169 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8B73192C-C22B-46D4-E040-BB89AD433800

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8B73192C-C22B-46D4-E040-BB89AD433800

Keywords

Versions (3)
  1. 4/19/12 4/19/12 -
  2. 2/4/15 2/4/15 - Martin Dugas
  3. 2/4/15 2/4/15 - Martin Dugas
Uploaded on

February 4, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Registration Enrollment Form (ENR AMC-053 )

German English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-053 Enrollment Form (ENR)
    1. No Instruction available.
Header Module
Description

Header Module

Principal Investigator
Description

PrincipalInvestigatorName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C19924
UMLS CUI-1
C1521895
Projected Start Date of Treatment
Description

TreatmentProjectedBeginDate

Data type

date

Measurement units
  • mm/dd/yyyy
Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25631
NCI Thesaurus Property
C25431
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
UMLS CUI-1
C3173309
mm/dd/yyyy
Karnofsky Performance Status
Description

KarnofskyPerformanceStatusScore

Data type

integer

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C20641
NCI Thesaurus ValueDomain
C25338
UMLS CUI-1
C0206065
Date Informed Consent Signed
Description

InformedConsentFormSignedDate

Data type

date

Measurement units
  • mm/dd/yyyy
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C16468
NCI Thesaurus Property
C25679
UMLS CUI-1
C2985782
mm/dd/yyyy
Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI-1
C0947611
Inclusion Criteria
Description

Inclusion Criteria

Alias
UMLS CUI-1
C1512693
Inclusion Criteria
Description

AIDSMalignancyConsortiumPatientInclusionClinicalTrialEligibilityCriteria053Type

Data type

integer

Measurement units
  • years
Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C16112
NCI Thesaurus Property-2
C25532
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0001779
years
Exclusion Criteria
Description

Exclusion Criteria

Alias
UMLS CUI-1
C0680251
Active hepatitis B infection
Description

AIDSMalignancyConsortiumPatientExclusionClinicalTrialEligibilityCriteria053Type

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C16112
NCI Thesaurus Property-2
C25370
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0744829
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-053 Enrollment Form (ENR)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Principal Investigator
Item
Principal Investigator
text
C25191 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C19924 (NCI Thesaurus ObjectClass)
C1521895 (UMLS CUI-1)
Treatment Begin Date
Item
Projected Start Date of Treatment
date
C15368 (NCI Thesaurus ObjectClass)
C25631 (NCI Thesaurus ObjectClass-2)
C25431 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C3173309 (UMLS CUI-1)
Karnofsky Performance Status
Item
Karnofsky Performance Status
integer
C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C0206065 (UMLS CUI-1)
Date Informed Consent Signed
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C16468 (NCI Thesaurus ObjectClass)
C25679 (NCI Thesaurus Property)
C2985782 (UMLS CUI-1)
Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI-1)
Item Group
Inclusion Criteria
C1512693 (UMLS CUI-1)
Patient age
Item
Inclusion Criteria
integer
C16960 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C16112 (NCI Thesaurus Property)
C25532 (NCI Thesaurus Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0001779 (UMLS CUI-1)
Item Group
Exclusion Criteria
C0680251 (UMLS CUI-1)
Hepatitis B active
Item
Active hepatitis B infection
boolean
C16960 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C16112 (NCI Thesaurus Property)
C25370 (NCI Thesaurus Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0744829 (UMLS CUI-1)
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