ID

2365

Description

S0201 Southwest Oncology Group Adjuvant Melanoma Off Treatment Notice Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93556CA-1C7B-6F30-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93556CA-1C7B-6F30-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Melanoma (Skin) null Off Treatment - S0201 Southwest Oncology Group Adjuvant Melanoma Off Treatment Notice - 2055669v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0201 Southwest Oncology Group Adjuvant Melanoma Off Treatment Notice
    1. No Instruction available.
Unnamed 1
Description

Unnamed 1

SWOG Patient No.
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Institution/Member
Description

MainMemberInstitution/Affiliate

Data type

text

Physician (Groups other than SWOG)
Description

TreatingPhysician

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Group Name
Description

ParticipatingGroupName

Data type

text

Study No.
Description

StudyNo.

Data type

text

Pt. No.
Description

Pt.ID

Data type

text

Unnamed 2
Description

Unnamed 2

Reason off Treatment (select one)
Description

OffTreatmentReason

Data type

text

Off Treatment due to the following toxicities
Description

OffTreatmentReason,Toxicity

Data type

text

Sites (progression or relapse)
Description

Sites(progressionorrelapse)

Data type

text

Other, specify (off treatment reason) (Date off treatment date of completion, death, or decision to discontinue therapy)
Description

OffTreatmentReason,Other

Data type

text

Will patient receive further treatment?
Description

FurtherTreatmentInd

Data type

text

Yes, specify (further treatment)
Description

FurtherTreatmentSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C25519
UMLS 2011AA ObjectClass
C1517331
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Date of Last Contact (or death)
Description

DeathDate/LastContactDate

Data type

date

Vital Status
Description

Patient'sVitalStatus

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

By
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date
Description

FormCompletionDate,Original

Data type

date

Ccrr Module For S0201 Southwest Oncology Group Adjuvant Melanoma Off Treatment Notice
Description

Ccrr Module For S0201 Southwest Oncology Group Adjuvant Melanoma Off Treatment Notice

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No Instruction available.

1 forms
  1. StudyEvent: S0201 Southwest Oncology Group Adjuvant Melanoma Off Treatment Notice
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed 1
SWOGPatientID
Item
SWOG Patient No.
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitialsName
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
MainMemberInstitution/Affiliate
Item
Institution/Member
text
TreatingPhysician
Item
Physician (Groups other than SWOG)
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
ParticipatingGroupName
Item
Group Name
text
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. No.
text
Item Group
Unnamed 2
Item
Reason off Treatment (select one)
text
CL.1
Code List
Reason off Treatment (select one)
CL Item
Treatment Completed Per Protocol Criteria (Treatment/observation completed per protocol)
CL Item
Toxicity/side Effects/complications (Toxicity, medically required, specify)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient refused, due to toxicity, specify)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient refused, other than toxicity, specify)
CL Item
Disease Progression, Relapse During Active Treatment (Progression or relapse)
CL Item
Death Of Patient Occurred After The Patient Began Protocol Therapy (Death)
CL Item
Other, Specify (Other, specify)
Item
Off Treatment due to the following toxicities
text
CL.2
Code List
Off Treatment due to the following toxicities
CL Item
granuloma (granuloma)
CL Item
local injection site reaction/pain (local injection site reaction/pain)
CL Item
flu-like symptoms (flu-like symptoms)
CL Item
other, specify in Comments (other, specify in Comments)
Item
Sites (progression or relapse)
text
CL.3
Code List
Sites (progression or relapse)
CL Item
Local Recurrence (local recurrence)
CL Item
In-transit Recurrence (in-transit recurrence)
CL Item
Regional Recurrence (regional recurrence)
CL Item
Distant Metastasis (distant metastasis)
C18206 (NCI Thesaurus)
C1269798 (UMLS 2011AA)
OffTreatmentReason,Other
Item
Other, specify (off treatment reason) (Date off treatment date of completion, death, or decision to discontinue therapy)
text
Item
Will patient receive further treatment?
text
CL.4
Code List
Will patient receive further treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
FurtherTreatmentSpecify
Item
Yes, specify (further treatment)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25519 (NCI Thesaurus ObjectClass)
C1517331 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
DeathDate/LastContactDate
Item
Date of Last Contact (or death)
date
Item
Vital Status
text
CL.5
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
Comments
Comments
Item
Comments
text
PersonCompletingForm,FirstName
Item
By
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date
date
Item Group
Ccrr Module For S0201 Southwest Oncology Group Adjuvant Melanoma Off Treatment Notice
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