ID

10654

Description

CALGB 90601: Supplemental Adverse Event Form (Thromboembolic Events) NCT00942331 Gemcitabine Hydrochloride and Cisplatin With or Without Bevacizumab in Treating Patients With Advanced Urinary Tract Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=65940F04-CD97-54E2-E040-BB89AD435A8C

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=65940F04-CD97-54E2-E040-BB89AD435A8C

Mots-clés

Versions (3)
  1. 26/08/2012 26/08/2012 -
  2. 08/01/2015 08/01/2015 - Martin Dugas
  3. 03/06/2015 03/06/2015 -
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3 juin 2015

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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CALGB 90601: Supplemental Adverse Event Form (Thromboembolic Events) NCT00942331

Anglais

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

1 Formulaires  
Header
Description

Header

CALGB Form (C-1766)
Description

Form ID CALGB

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3262252
NCI Thesaurus ObjectClass
C19464
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass-2
C25442
CALGB Study No.
Description

Protocol ID CALGB

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
CALGB Patient ID
Description

Trial subject ID CALGB

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
Reporting period start date
Description

Reporting Period Start Date

Type de données

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25616
UMLS CUI-1
C2361257
NCI Thesaurus Property-2
C25651
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
Reporting period end date
Description

Reporting Period End Date

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2361259
NCI Thesaurus Property
C25616
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property-2
C25651
Are data amended
Description

Data amended

Type de données

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Patient demographics
Description

Patient demographics

Patient Initials (Last, First Middle)
Description

Patient Initials

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Hospital No.
Description

Medical Record Number

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301894
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25261
NCI Thesaurus Property-2
C25198
Institution/Affiliate
Description

Institution Name

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Participating Group
Description

Participating Group

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2347449
NCI Thesaurus ObjectClass
C25608
NCI Thesaurus ObjectClass-2
C17005
NCI Thesaurus Property
C25364
Participating Group Study No.
Description

Study Number Participating Group

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Participating Group Patient ID
Description

Trial subject ID Participating Group

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Assessment of medication
Description

Assessment of medication

Cycle number
Description

Cycle Number

Type de données

integer

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2045829
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25379
Medications received during this reporting period (Mark one with an X)
Description

ReceivedMedicationReportingPeriodType

Type de données

text

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass-2
C25639
UMLS 2011AA ObjectClass-2
C1514756
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NSAID, specify
Description

NonsteroidalAntiinflammatoryDrugMedicationReportingPeriodSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass-2
C257
UMLS 2011AA ObjectClass-2
C0003211
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Anti-platelet, specify
Description

AntiplateletMedicationReportingPeriodSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ObjectClass-2
C1327
UMLS 2011AA ObjectClass-2
C0085826
Statin, specify
Description

LipidLoweringMedicationReportingPeriodSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Metathesaurus ObjectClass
CL264271
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
BP or cardiac medication, specify
Description

CardiacMedicationReportingPeriodSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C13306
UMLS 2011AA ObjectClass
C1522601
NCI Thesaurus ObjectClass-2
C459
UMLS 2011AA ObjectClass-2
C0013227
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Anticoagulant, specify
Description

AnticoagulantMedicationReportingPeriodSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass-2
C263
UMLS 2011AA ObjectClass-2
C0003280
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Which of the following arterial thrombotic events (ATEs) occurred during this reporting period? (Mark one with an X)
Description

ArterialThrombosisReportingPeriodType

Type de données

text

Alias
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Metathesaurus ObjectClass
C0221464
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Other arterial event, specify
Description

ArterialThrombosisReportingPeriodSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Metathesaurus ObjectClass
C0221464
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Treatment for ATE (Mark one with an X)
Description

ArterialThrombosisTherapyType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus Property
C15368
NCI Metathesaurus ObjectClass
C0221464
Outcome of ATE (Mark one with an X)
Description

ArterialThrombosisOutcomeType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Metathesaurus ObjectClass
C0221464
NCI Metathesaurus Property
CL158230
Which of the following venous thrombotic events (VTEs) occurred during this reporting period? (Mark one with an X)
Description

VenousThrombosisReportingPeriodType

Type de données

text

Alias
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus ObjectClass-2
C25291
UMLS 2011AA ObjectClass-2
C0348013
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Other venous thrombotic event, specify
Description

VenousThrombosisReportingPeriodSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus ObjectClass-2
C25291
UMLS 2011AA ObjectClass-2
C0348013
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Specify status
Description

VenousThrombosisReportingPeriodStatus

Type de données

text

Alias
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus ObjectClass-2
C25291
UMLS 2011AA ObjectClass-2
C0348013
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Treatment for VTE (Mark one with an X)
Description

VenousThrombosisTreatmentType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus ObjectClass-2
C25291
UMLS 2011AA ObjectClass-2
C0348013
NCI Metathesaurus Property
C0087111
Outcome of VTE (Mark one with an X)
Description

VenousThrombosisOutcomeType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C26891
UMLS 2011AA ObjectClass
C0040053
NCI Thesaurus ObjectClass-2
C25291
UMLS 2011AA ObjectClass-2
C0348013
NCI Metathesaurus Property
CL158230
Completed by
Description

Person Completing Form

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Date form completed
Description

Date Form Completed

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
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Similar models

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Header
Form ID CALGB
Item
CALGB Form (C-1766)
text
C25337 (NCI Thesaurus ValueDomain)
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)
Protocol ID CALGB
Item
CALGB Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Trial subject ID CALGB
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Reporting Period Start Date
Item
Reporting period start date
date
C15368 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C2361257 (UMLS CUI-1)
C25651 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
Reporting Period End Date
Item
Reporting period end date
date
C25164 (NCI Thesaurus ValueDomain)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
Data amended
Item
Are data amended
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Patient demographics
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Medical Record Number
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Participating Group
Item
Participating Group
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Assessment of medication
Cycle Number
Item
Cycle number
integer
C25337 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
Item
Medications received during this reporting period (Mark one with an X)
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus ObjectClass-2)
C1514756 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
Medications received during this reporting period (Mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Aspirin (Aspirin)
CL Item
Nsaid (NSAID)
CL Item
Anti-platelet (Anti-platelet)
CL Item
Statin (Statin)
CL Item
Bp Or Cardiac Medication (BP or cardiac medication)
CL Item
Anticoagulant (Anticoagulant)
NonsteroidalAntiinflammatoryDrugMedicationReportingPeriodSpecify
Item
NSAID, specify
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C257 (NCI Thesaurus ObjectClass-2)
C0003211 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
AntiplateletMedicationReportingPeriodSpecify
Item
Anti-platelet, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C1327 (NCI Thesaurus ObjectClass-2)
C0085826 (UMLS 2011AA ObjectClass-2)
LipidLoweringMedicationReportingPeriodSpecify
Item
Statin, specify
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
CL264271 (NCI Metathesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
CardiacMedicationReportingPeriodSpecify
Item
BP or cardiac medication, specify
text
C13306 (NCI Thesaurus ObjectClass)
C1522601 (UMLS 2011AA ObjectClass)
C459 (NCI Thesaurus ObjectClass-2)
C0013227 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
AnticoagulantMedicationReportingPeriodSpecify
Item
Anticoagulant, specify
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C263 (NCI Thesaurus ObjectClass-2)
C0003280 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Which of the following arterial thrombotic events (ATEs) occurred during this reporting period? (Mark one with an X)
text
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C0221464 (NCI Metathesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.3
Code List
Which of the following arterial thrombotic events (ATEs) occurred during this reporting period? (Mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Myocardial Infarction (Myocardial infarction)
C27996 (NCI Thesaurus)
C0027051 (UMLS 2011AA)
CL Item
Angina (Angina)
C51221 (NCI Thesaurus)
C0002962 (UMLS 2011AA)
CL Item
Cva - Thrombotic (CVA - thrombotic)
CL Item
Cva - Hemorrhagic (CVA - hemorrhagic)
CL Item
Transient Ischemic Attack (Transient ischemic attack)
CL Item
Other Arterial Event (Other arterial event)
ArterialThrombosisReportingPeriodSpecify
Item
Other arterial event, specify
text
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C0221464 (NCI Metathesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Treatment for ATE (Mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
C0221464 (NCI Metathesaurus ObjectClass)
CL.4
Code List
Treatment for ATE (Mark one with an X)
CL Item
Outpatient Management Only (Outpatient management only)
CL Item
Emergency Room (Emergency room)
CL Item
Hospitalization (Hospitalization)
Item
Outcome of ATE (Mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C0221464 (NCI Metathesaurus ObjectClass)
CL158230 (NCI Metathesaurus Property)
CL.5
Code List
Outcome of ATE (Mark one with an X)
CL Item
Resolved (Resolved)
C49498 (NCI Thesaurus)
C1709863 (UMLS 2011AA)
CL Item
Not Resolved (Not resolved)
CL Item
Resulted In Death (Resulted in death)
Item
Which of the following venous thrombotic events (VTEs) occurred during this reporting period? (Mark one with an X)
text
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C25291 (NCI Thesaurus ObjectClass-2)
C0348013 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
Which of the following venous thrombotic events (VTEs) occurred during this reporting period? (Mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Catheter Related (Catheter related)
CL Item
Dvt (DVT)
CL Item
Pulmonary Embolism (Pulmonary embolism)
CL Item
Other Venous Thrombotic Event (Other venous thrombotic event)
VenousThrombosisReportingPeriodSpecify
Item
Other venous thrombotic event, specify
text
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C25291 (NCI Thesaurus ObjectClass-2)
C0348013 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Specify status
text
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C25291 (NCI Thesaurus ObjectClass-2)
C0348013 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.7
Code List
Specify status
CL Item
Asymptomatic (asymptomatic)
C3833 (NCI Thesaurus)
C0231221 (UMLS 2011AA)
CL Item
Symptomatic (symptomatic)
C25269 (NCI Thesaurus)
C0231220 (UMLS 2011AA)
Item
Treatment for VTE (Mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C25291 (NCI Thesaurus ObjectClass-2)
C0348013 (UMLS 2011AA ObjectClass-2)
C0087111 (NCI Metathesaurus Property)
CL.8
Code List
Treatment for VTE (Mark one with an X)
CL Item
Outpatient Management Only (Outpatient management only)
CL Item
Emergency Room (Emergency room)
CL Item
Hospitalization (Hospitalization)
Item
Outcome of VTE (Mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C26891 (NCI Thesaurus ObjectClass)
C0040053 (UMLS 2011AA ObjectClass)
C25291 (NCI Thesaurus ObjectClass-2)
C0348013 (UMLS 2011AA ObjectClass-2)
CL158230 (NCI Metathesaurus Property)
CL.9
Code List
Outcome of VTE (Mark one with an X)
CL Item
Resolved (Resolved)
C49498 (NCI Thesaurus)
C1709863 (UMLS 2011AA)
CL Item
Not Resolved (Not resolved)
CL Item
Resulted In Death (Resulted in death)
Person Completing Form
Item
Completed by
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Date Form Completed
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
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