ID

9999

Description

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

Lien

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

Mots-clés

Versions (2)
  1. 26/08/2012 26/08/2012 -
  2. 13/03/2015 13/03/2015 - Martin Dugas
Téléchargé le

13 mars 2015

DOI

Pour une demande vous connecter.

Licence

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

Anglais

No Instruction available.

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

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Description

HospitalAdmissionOrdinalNumber

Type de données

integer

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

ResearchCommentsText

Type de données

text

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

Missed Visit Information

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

PatientAbsentVisitDate

Type de données

date

Unités de mesure
  • 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
Description

PatientAbsentVisitReason

Type de données

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
Description

PatientAbsentVisitSpecify

Type de données

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.)
Description

PatientScheduleNextVisitInd-2

Type de données

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 Formulaires
  1. StudyEvent: AMC-058 Missed Visit Form (F35)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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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