ID

26137

Description

AMC-070 Off-Study Summary Form (F50) Lenalidomide in Treating Patients With AIDS-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=91E448E8-A18B-E89F-E040-BB89AD433766

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=91E448E8-A18B-E89F-E040-BB89AD433766

Keywords

  1. 10/9/17 10/9/17 -
Copyright Holder

AIDS Malignancy Consortium

Uploaded on

October 9, 2017

DOI

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License

Creative Commons BY-NC 3.0

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AMC-070 Off-Study Summary Form (F50)

Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)

Ccrr Module For Off Study Summary - Rf50
Description

Ccrr Module For Off Study Summary - Rf50

Alias
UMLS CUI-1
C1518546
UMLS CUI-2
C1706244
Off Study Date
Description

Off-TreatmentStudyFollow-UpEndDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
NCI Thesaurus Property
C25275
UMLS CUI [1,1]
C1518546
UMLS CUI [1,2]
C0011008
Off Study Reason
Description

Off-TreatmentStudyFollow-UpReason (select the primary reason)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
UMLS CUI [1,1]
C1518546
UMLS CUI [1,2]
C0392360
Other, specify
Description

Off-TreatmentStudyFollow-UpSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
UMLS CUI [1,1]
C1518546
UMLS CUI [1,2]
C0392360
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1518546

Similar models

Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Off Study Summary - Rf50
C1518546 (UMLS CUI-1)
C1706244 (UMLS CUI-2)
Off Study Date
Item
Off Study Date
date
C25164 (NCI Thesaurus ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C25275 (NCI Thesaurus Property)
C1518546 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Off Study Reason
text
C25638 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1518546 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Code List
Off Study Reason
CL Item
Protocol-defined Follow-up Completed (Protocol-defined follow-up completed)
CL Item
Lost To Follow-up (Patient lost to follow-up)
CL310949 (NCI Metathesaurus)
CL Item
Patient Refused Follow-up (Patient refused follow-up)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Adverse Event/side Effects/complications (Adverse Event/Side Effects/Complications)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other, specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1518546 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])

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