ID

9999

Descripción

AMC-058 Missed Visit Form (F35) Detecting Anal and Genital Human Papillomavirus Infection and Squamous Intraepithelial Lesions in HIV-Positive Patients Enrolled in AIDS Cancer Clinical Trials NCT00695422 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84985F78-ADFC-9672-E040-BB89AD43767C

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84985F78-ADFC-9672-E040-BB89AD43767C

Palabras clave

Versiones (2)
  1. 26/8/12 26/8/12 -
  2. 13/3/15 13/3/15 - Martin Dugas
Subido en

13 de marzo de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Aids-related Malignancies NCT00695422 On-Study - AMC-058 Missed Visit Form (F35) - 3063630v1.0

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: AMC-058 Missed Visit Form (F35)
    1. No Instruction available.
Header Module
Descripción

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Descripción

HospitalAdmissionOrdinalNumber

Tipo de datos

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI-1
C1549755
Comments
Descripción

ResearchCommentsText

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI-1
C0947611
Missed Visit Information
Descripción

Missed Visit Information

Alias
UMLS CUI-1
C1705492
UMLS CUI-2
C1512346
Missed Visit Date
Descripción

PatientAbsentVisitDate

Tipo de datos

date

Unidades de medida
  • mm/dd/yyyy
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C48190
NCI Thesaurus Property-2
C25716
UMLS CUI-1
C1705492
UMLS CUI-2
C1512346
UMLS CUI-3
C0011008
mm/dd/yyyy
Reason patient missed visit
Descripción

PatientAbsentVisitReason

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C48190
NCI Thesaurus Property-2
C25716
UMLS CUI-1
C0392360
UMLS CUI-2
C0030705
UMLS CUI-3
C0332197
UMLS CUI-4
C0545082
Other, specify
Descripción

PatientAbsentVisitSpecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C48190
NCI Thesaurus Property-2
C25716
UMLS CUI-1
C1521902
UMLS CUI-2
C0030705
UMLS CUI-3
C0332197
UMLS CUI-4
C0545082
Next visit scheduled (Items missed will be made up at the new visit.)
Descripción

PatientScheduleNextVisitInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C53286
NCI Thesaurus Property-2
C25211
NCI Thesaurus Property-3
C25716
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0184760
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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: AMC-058 Missed Visit Form (F35)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
HospitalAdmissionOrdinalNumber
Item
Visit number
integer
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI-1)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI-1)
Item Group
Missed Visit Information
C1705492 (UMLS CUI-1)
C1512346 (UMLS CUI-2)
Missed Visit Date
Item
Missed Visit Date
date
C25164 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C48190 (NCI Thesaurus Property)
C25716 (NCI Thesaurus Property-2)
C1705492 (UMLS CUI-1)
C1512346 (UMLS CUI-2)
C0011008 (UMLS CUI-3)
Item
Reason patient missed visit
text
C25638 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C48190 (NCI Thesaurus Property)
C25716 (NCI Thesaurus Property-2)
C0392360 (UMLS CUI-1)
C0030705 (UMLS CUI-2)
C0332197 (UMLS CUI-3)
C0545082 (UMLS CUI-4)
CL.1
Code List
Reason patient missed visit
CL Item
Patient Forgot (1)
CL Item
Health Reasons (2)
CL Item
Patient Could Not Get Off Work (3)
CL Item
Patient Unable To Obtain Dependent Care (4)
CL Item
Patient Had Transportation Problems (5)
CL Item
Patient Unhappy With Frequency Of Visits (6)
CL Item
Scheduling Difficulties (7)
CL Item
Patient Decided To Discontinue Study (8)
CL Item
Patient Experienced An Adverse Event (9)
CL Item
Other (10)
Patient Absent Visit Specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C48190 (NCI Thesaurus Property)
C25716 (NCI Thesaurus Property-2)
C1521902 (UMLS CUI-1)
C0030705 (UMLS CUI-2)
C0332197 (UMLS CUI-3)
C0545082 (UMLS CUI-4)
Patient follow-up planned and scheduled
Item
Next visit scheduled (Items missed will be made up at the new visit.)
boolean
C16960 (NCI Thesaurus ObjectClass)
C53286 (NCI Thesaurus Property)
C25211 (NCI Thesaurus Property-2)
C25716 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C0184760 (UMLS CUI-1)
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