ID

2798

Beschreibung

The Division of Cancer Prevention's tobacco assessment case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=519D5ABC-8BA7-5C35-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=519D5ABC-8BA7-5C35-E044-0003BA3F9857

Stichworte

Versionen (2)
  1. 19.09.12 19.09.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

19. September 2012

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy
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Tobacco Use Assessment - 2764420v1.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: Tobacco Use Assessment
    1. No Instruction available.
Screening
Beschreibung

Screening

DCP Protocol #
Beschreibung

ProtocolNCIIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C19202
UMLS 2011AA Property
C1513882
Institution Code
Beschreibung

NationalCancerInstituteInstituteCode

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant ID
Beschreibung

ParticipantIdentifier

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25364
UMLS 2011AA ValueDomain
C0600091
Visit Type
Beschreibung

VisitTypeText

Datentyp

text

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Visit Date
Beschreibung

VisitDate

Datentyp

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Tobacco Assessment
Beschreibung

Tobacco Assessment

Have you smoked 100 cigarettes or more during your entire lifetime?
Beschreibung

SmokingHistoryLifetimeIndicator

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Section 1
Beschreibung

Section 1

Age in years
Beschreibung

AgeBeganSmokinginYears

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property
C18270
UMLS 2011AA Property
C0700219
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25150
UMLS 2011AA ValueDomain
C0001779
At what age did you begin smoking regularly?
Beschreibung

ParticipantCigaretteSmokingRegularType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property
C18270
UMLS 2011AA Property
C0700219
Do you currently smoke cigarettes regularly?
Beschreibung

CigaretteUseCurrentStatus

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C1802
UMLS 2011AA ObjectClass
C0677453
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
Age in years
Beschreibung

AgeDiscontinuedSmokinginYears

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Thesaurus Property
C25484
UMLS 2011AA Property
C1444662
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25150
UMLS 2011AA ValueDomain
C0001779
At what age did you stop smoking cigarettes on a regular basis?
Beschreibung

ParticipantCigaretteSmokingDiscontinuedRegularType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25484
UMLS 2011AA Property
C1444662
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
Years (How many years have you been smoking or did smoke regularly?)
Beschreibung

CigarettesSmokingYearNumber

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C1802
UMLS 2011AA ObjectClass
C0677453
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus Property
C17934
UMLS 2011AA Property
C0453996
Not Obtained
Beschreibung

NotObtainedIndicator

Datentyp

text

Alias
NCI Thesaurus Property
C25180
UMLS 2011AA Property
C1522602
NCI Metathesaurus ObjectClass
CL310460
NCI Metathesaurus ObjectClass
CL052458
NCI Metathesaurus ValueDomain
C0021212
On the average, about how many cigarettes a day do (or did) you smoke? (1 pack = 20 cigarettes Number of Cigarettes per day)
Beschreibung

BaselineSmokeAverageDayValue

Datentyp

text

Alias
NCI Thesaurus Property
C17934
UMLS 2011AA Property
C0453996
NCI Thesaurus ObjectClass
C18772
UMLS 2011AA ObjectClass
C0262926
NCI Metathesaurus ValueDomain
CL052797
Tobacco Assessment - Section 2
Beschreibung

Tobacco Assessment - Section 2

Have you ever smoked this type of tobacco on a regular basis?
Beschreibung

ParticipantTobaccoSmokingType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17934
UMLS 2011AA Property
C0453996
Response
Beschreibung

TobaccoTypeResponseIndicator

Datentyp

text

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C891
UMLS 2011AA ObjectClass
C0040329
If yes, how many years did you smoke this type of tobacco?
Beschreibung

TobaccoTypeYearsSmokedNumber

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ObjectClass
C891
UMLS 2011AA ObjectClass
C0040329
If yes, how many did you usually smoke in a day?
Beschreibung

TobaccoTypeSmokingAverageNumber

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ObjectClass
C891
UMLS 2011AA ObjectClass
C0040329
per
Beschreibung

ExaminationTimepointType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C68568
UMLS 2011AA Property
C2348792
NCI Thesaurus ValueDomain
C68568
UMLS 2011AA ValueDomain
C2348792
NCI Thesaurus ObjectClass
C25305
UMLS 2011AA ObjectClass
C0582103
Dcp Template Footer
Beschreibung

Dcp Template Footer

Protocol Title
Beschreibung

ProtocolTitleName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C42774
UMLS 2011AA Property
C1705823
Protocol Version
Beschreibung

ProtocolVersion

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Protocol Date
Beschreibung

ProtocolVersionDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25367
Page #
Beschreibung

PageNumber

Datentyp

double

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Metathesaurus ObjectClass
C0439643
Total Page Number
Beschreibung

CaseReportFormTotalPageNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus Property
C25304
UMLS 2011AA Property
C0439810
NCI Thesaurus Property
C42783
UMLS 2011AA Property
C1704732
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
DCP Template Version
Beschreibung

DCPTemplateVersionText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Metathesaurus ObjectClass
C0728990
NCI Thesaurus Property
C25714
UMLS 2011AA Property
C0333052
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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: Tobacco Use Assessment
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Screening
ProtocolNCIIdentifierNumber
Item
DCP Protocol #
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C19202 (NCI Thesaurus Property)
C1513882 (UMLS 2011AA Property)
NationalCancerInstituteInstituteCode
Item
Institution Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ParticipantIdentifier
Item
Participant ID
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
VisitTypeText
Item
Visit Type
text
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
VisitDate
Item
Visit Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
Item Group
Tobacco Assessment
Item
Have you smoked 100 cigarettes or more during your entire lifetime?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
CL.1
Code List
Have you smoked 100 cigarettes or more during your entire lifetime?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
AgeBeganSmokinginYears
Item
Age in years
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property)
C0700219 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25150 (NCI Thesaurus ValueDomain)
C0001779 (UMLS 2011AA ValueDomain)
Item
At what age did you begin smoking regularly?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property)
C0700219 (UMLS 2011AA Property)
CL.2
Code List
At what age did you begin smoking regularly?
CL Item
Don't Know (Don't know)
CL Item
Never Regular (Never regular)
Item
Do you currently smoke cigarettes regularly?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1802 (NCI Thesaurus ObjectClass)
C0677453 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
CL.3
Code List
Do you currently smoke cigarettes regularly?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
AgeDiscontinuedSmokinginYears
Item
Age in years
double
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25150 (NCI Thesaurus ValueDomain)
C0001779 (UMLS 2011AA ValueDomain)
Item
At what age did you stop smoking cigarettes on a regular basis?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
CL.4
Code List
At what age did you stop smoking cigarettes on a regular basis?
CL Item
Don't Know (Don't know)
CL Item
Still Smoking (Still smoking)
CigarettesSmokingYearNumber
Item
Years (How many years have you been smoking or did smoke regularly?)
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C1802 (NCI Thesaurus ObjectClass)
C0677453 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus Property)
C0453996 (UMLS 2011AA Property)
Item
Not Obtained
text
C25180 (NCI Thesaurus Property)
C1522602 (UMLS 2011AA Property)
CL310460 (NCI Metathesaurus ObjectClass)
CL052458 (NCI Metathesaurus ObjectClass)
C0021212 (NCI Metathesaurus ValueDomain)
CL.5
Code List
Not Obtained
CL Item
Don't Know (Don't Know)
BaselineSmokeAverageDayValue
Item
On the average, about how many cigarettes a day do (or did) you smoke? (1 pack = 20 cigarettes Number of Cigarettes per day)
text
C17934 (NCI Thesaurus Property)
C0453996 (UMLS 2011AA Property)
C18772 (NCI Thesaurus ObjectClass)
C0262926 (UMLS 2011AA ObjectClass)
CL052797 (NCI Metathesaurus ValueDomain)
Item Group
Tobacco Assessment - Section 2
Item
Have you ever smoked this type of tobacco on a regular basis?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17934 (NCI Thesaurus Property)
C0453996 (UMLS 2011AA Property)
CL.6
Code List
Have you ever smoked this type of tobacco on a regular basis?
CL Item
Non-filtered (plain) Cigarettes (Non-filtered (plain) cigarettes)
CL Item
Filtered Cigarettes (Filtered cigarettes)
CL Item
Low Tar Cigarettes (Low tar cigarettes)
CL Item
Pipe (Pipe)
CL Item
Cigar (Cigar)
C1813 (NCI Thesaurus)
C0182504 (UMLS 2011AA)
Item
Response
text
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
CL.7
Code List
Response
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
TobaccoTypeYearsSmokedNumber
Item
If yes, how many years did you smoke this type of tobacco?
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
TobaccoTypeSmokingAverageNumber
Item
If yes, how many did you usually smoke in a day?
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
Item
per
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C68568 (NCI Thesaurus Property)
C2348792 (UMLS 2011AA Property)
C68568 (NCI Thesaurus ValueDomain)
C2348792 (UMLS 2011AA ValueDomain)
C25305 (NCI Thesaurus ObjectClass)
C0582103 (UMLS 2011AA ObjectClass)
CL.8
Code List
per
CL Item
Day (day)
C25301 (NCI Thesaurus)
C0439228 (UMLS 2011AA)
CL Item
Week (week)
C29844 (NCI Thesaurus)
C0439230 (UMLS 2011AA)
CL Item
Month (month)
C29846 (NCI Thesaurus)
C0439231 (UMLS 2011AA)
Item Group
Dcp Template Footer
ProtocolTitleName
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)
ProtocolVersion
Item
Protocol Version
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolVersionDate
Item
Protocol Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
PageNumber
Item
Page #
double
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0439643 (NCI Metathesaurus ObjectClass)
CaseReportFormTotalPageNumber
Item
Total Page Number
text
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C42783 (NCI Thesaurus Property)
C1704732 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
DCPTemplateVersionText
Item
DCP Template Version
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C0728990 (NCI Metathesaurus ObjectClass)
C25714 (NCI Thesaurus Property)
C0333052 (UMLS 2011AA Property)
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