Follow-Up - Advanced Bladder/Urothelial Cancer - Follow-Up Form - 2019343v2.31
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Advanced Bladder/Urothelial Cancer - Follow-Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A976-3FA4-E034-080020C9C0E0

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2015-01-09 by Martin Dugas

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    Bladder/urothelial: Long-term Toxicity






    S.2019343v2.31

    Advanced Bladder/Urothelial Cancer - Follow-Up Form

    Crf Header

    Name: CRF Header
    Description: Crf Header

    Name Protocol ID Coordinating Group
    Question Coordinating Group Protocol No.
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25337
    UMLS CUI-1 C3274381
    NCI Thesaurus ObjectClass C25320
    UMLS CUI-2 C1711341
    NCI Thesaurus Property C25462
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus Property-2 C25364
    Name Coordinating Group Code
    Question Coordinating Group Code
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25162
    UMLS CUI-1 C1711341
    NCI Thesaurus ObjectClass C17005
    UMLS CUI-2 C0805701
    NCI Thesaurus ObjectClass-2 C25462
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus Property C25364
    Name Protocol Title
    Question Protocol Title
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25191
    UMLS CUI-1 C2986303
    NCI Thesaurus ObjectClass C25320
    NCI Thesaurus Property C42774
    Name Patient Study ID
    Question Patient Study ID
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25337
    UMLS CUI-1 C2348585
    NCI Thesaurus ObjectClass C16960
    NCI Thesaurus Property C25462
    NCI Thesaurus Property-2 C25364
    Name Trial subject ID Participating Group
    Question Other Patient ID
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25337
    UMLS CUI-1 C2348585
    NCI Thesaurus ObjectClass C16960
    UMLS CUI-2 C2347449
    NCI Thesaurus Property C25608
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus Property-2 C25364
    Name Institution Name
    Question Institution/Affiliate
    Datatype text
    Aliases:  
    NCI Thesaurus ObjectClass C25454
    UMLS CUI-1 C1301943
    NCI Thesaurus ObjectClass-2 C21541
    NCI Thesaurus Property C25364
    NCI Thesaurus ValueDomain C25191
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus ValueDomain-2 C21541
    Name ParticipatingGroupIdentifierCode
    Question Participating Group Code
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25162
    UMLS 2011AA ValueDomain C0805701
    NCI Thesaurus ObjectClass C25608
    UMLS 2011AA ObjectClass C0679823
    NCI Thesaurus ObjectClass-2 C17005
      ...
      There are 3 more alias. Click to show them.
    UMLS 2011AA ObjectClass-2 C1257890
    NCI Thesaurus Property C25364
    UMLS 2011AA Property C0600091
    Name Patient Name
    Question Patient Name (initials acceptable)
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25191
    UMLS CUI-1 C1299487
    NCI Thesaurus ObjectClass C16960
    NCI Thesaurus Property C25364

    Breast: Form Administration

    Name: Bladder/Urothelial: Form Administration
    Description: Breast: Form Administration

    Name Person Completing Form
    Question Person Completing Form
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25191
    UMLS CUI-1 C1550483
    NCI Thesaurus ObjectClass C25657
    NCI Thesaurus Property C25364
    Name Data amended
    Question Are data amended (If data are amended, please circle in red when using paper form)
    Datatype boolean
    Aliases:  
    NCI Thesaurus ValueDomain C38148
    UMLS CUI-1 C0680532
    NCI Thesaurus ObjectClass C25474
    NCI Thesaurus Property C25416

    Bladder/urothelial: Vital Status

    Name: Bladder/Urothelial: Vital Status
    Description: Bladder/urothelial: Vital Status

    Name Patient Status
    Question Patient Vital Status
    Datatype text
    Aliases:  
    NCI Thesaurus ObjectClass C16960
    UMLS CUI-1 C3846084
    NCI Thesaurus ValueDomain C18003
    NCI Thesaurus ValueDomain-2 C25688
    NCI Thesaurus Property C25717
    Codelistitems  
      Alive(Alive)
      Dead(Dead)
    Name Primary Cause of Death
    Question Primary Cause of Death (check one)
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25638
    UMLS CUI-1 C0007465
    NCI Thesaurus ObjectClass C16960
    NCI Thesaurus Property C28554
    NCI Thesaurus ValueDomain-2 C25251
    Codelistitems  
      Due To Other Cause(Due to other cause)
      Due To Protocol Treatment(Due to protocol treatment)
      Due To This Disease(Due to this disease)
      Unknown(Unknown)
    Name Cause of Death, specify
    Question Describe cause of death
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25685
    UMLS CUI-1 C0007465
    NCI Thesaurus ObjectClass C16960
    UMLS CUI-2 C1521902
    NCI Thesaurus Property C28554
    Name Date last contact
    Question Date of Last Contact or Death
    Datatype date
    Aliases:  
    NCI Thesaurus ObjectClass C16960
    UMLS CUI-1 C0805839
    NCI Thesaurus Property C25461
    NCI Thesaurus Property-2 C25551
    NCI Thesaurus ValueDomain C25164
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus ValueDomain-2 C25367

    Bladder/urothelial: Disease Follow-up Status

    Name: Bladder/Urothelial: Disease Follow-up Status
    Description: Bladder/urothelial: Disease Follow-up Status

    Name Documented clinical assessment for this cancer
    Question Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
    Datatype boolean
    Aliases:  
    NCI Thesaurus ValueDomain C38148
    UMLS CUI-1 C1522577
    NCI Thesaurus Property C16033
    UMLS CUI-2 C0006826
    NCI Thesaurus ObjectClass C9305
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus Property-2 C25365
    Name Follow-Up Date
    Question Date of Last Clinical Assessment (only provide date if assessment since submission of previous follow-up form)
    Datatype date
    Aliases:  
    NCI Thesaurus ObjectClass C9305
    UMLS CUI-1 C3694716
    NCI Thesaurus Property C16033
    NCI Thesaurus Property-2 C25365
    NCI Thesaurus ValueDomain C25164
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus ValueDomain-2 C25367

    Bladder/urothelial: Notice Of Progression

    Name: Bladder/Urothelial: Notice of Progression
    Description: Bladder/urothelial: Notice Of Progression

    Name ProgressionLocalRecurrentNeoplasmPresentInd-3
    Question Has the patient been diagnosed with a local recurrence (non-nodal site) (that has not been previously reported)
    Datatype boolean
    Aliases:  
    NCI Thesaurus ObjectClass C25331
    NCI Thesaurus Property C25626
    UMLS 2011AA Property C0150312
    NCI Thesaurus Property-2 C25388
    UMLS 2011AA Property-2 C1947913
      ...
      There are 4 more alias. Click to show them.
    NCI Thesaurus Property-3 C4798
    UMLS 2011AA Property-3 C0521158
    NCI Thesaurus ValueDomain C38148
    UMLS 2011AA ValueDomain C1512699
    Name FirstProgressionLocalAnatomicLocationDate
    Question Date of First Local Progression
    Datatype date
    Aliases:  
    NCI Thesaurus ObjectClass C25331
    NCI Thesaurus ObjectClass-2 C25509
    UMLS 2011AA ObjectClass C1279901
    NCI Thesaurus Property C25341
    UMLS 2011AA Property C0450429
      ...
      There are 6 more alias. Click to show them.
    NCI Thesaurus Property-2 C25421
    UMLS 2011AA Property-2 C0002808
    NCI Metathesaurus Property C0443133
    NCI Thesaurus ValueDomain C25164
    UMLS 2011AA ValueDomain C0011008
    NCI Thesaurus ValueDomain-2 C25367
    Name FirstBladderProgressionLocalAnatomicSite
    Question Site of First Local Progression (s - mark all that apply)
    Datatype text
    Aliases:  
    NCI Thesaurus ObjectClass C25331
    NCI Thesaurus ObjectClass-2 C12414
    UMLS 2011AA ObjectClass C0005682
    NCI Thesaurus ObjectClass-3 C25509
    UMLS 2011AA ObjectClass-2 C1279901
      ...
      There are 7 more alias. Click to show them.
    NCI Thesaurus Property C25341
    UMLS 2011AA Property C0450429
    NCI Thesaurus Property-2 C25421
    UMLS 2011AA Property-2 C0002808
    NCI Metathesaurus Property C0443133
    NCI Thesaurus ValueDomain C13717
    UMLS 2011AA ValueDomain C1515974
    Codelistitems  
      Abdominal Wall(Abdominal wall)
      Other Specify(Other)
      Pelvic Wall(Pelvic wall)
      Peritoneum(Peritoneum)
      Prostate Gland(Prostate)
      ...
      There are 4 more items on this list. Click to show them.
      Skin(Skin)
      Urethra(Urethra)
      Uterus(Uterus)
      Vagina(Vagina)
    Name FirstProgressionLocalAnatomicLocationSpecify
    Question Other specify
    Datatype text
    Aliases:  
    NCI Thesaurus ObjectClass C25331
    NCI Thesaurus ObjectClass-2 C25509
    UMLS 2011AA ObjectClass C1279901
    NCI Thesaurus Property C25341
    UMLS 2011AA Property C0450429
      ...
      There are 5 more alias. Click to show them.
    NCI Thesaurus Property-2 C25421
    UMLS 2011AA Property-2 C0002808
    NCI Metathesaurus Property C0443133
    NCI Thesaurus ValueDomain C25685
    UMLS 2011AA ValueDomain C1521902
    Name LocalLymphNodeProgressionInd-3
    Question Has the patient been diagnosed with a local-regional lymph node recurrence that has not been previously reported
    Datatype boolean
    Aliases:  
    NCI Thesaurus ValueDomain C38148
    UMLS 2011AA ValueDomain C1512699
    NCI Thesaurus Property C25331
    NCI Thesaurus ObjectClass C12745
    UMLS 2011AA ObjectClass C0024204
      ...
      There are 2 more alias. Click to show them.
    NCI Thesaurus ObjectClass-2 C25388
    UMLS 2011AA ObjectClass-2 C1947913
    Name FirstLymphNodeLocal-RegionalProgressionDate
    Question Date of First Local-Regional Lymph Node Progression
    Datatype date
    Aliases:  
    NCI Thesaurus ObjectClass C12745
    UMLS 2011AA ObjectClass C0024204
    NCI Thesaurus ObjectClass-2 C25509
    UMLS 2011AA ObjectClass-2 C1279901
    NCI Thesaurus Property C25331
      ...
      There are 5 more alias. Click to show them.
    NCI Thesaurus Property-2 C25388
    UMLS 2011AA Property C1947913
    NCI Thesaurus ValueDomain C25164
    UMLS 2011AA ValueDomain C0011008
    NCI Thesaurus ValueDomain-2 C25367
    Name FirstLymphNodeLocal-RegionalProgressionSite
    Question Site of First Local-Regional Lymph Node Progression (s - mark all that apply)
    Datatype text
    Aliases:  
    NCI Thesaurus ObjectClass C12745
    UMLS 2011AA ObjectClass C0024204
    NCI Thesaurus ObjectClass-2 C25509
    UMLS 2011AA ObjectClass-2 C1279901
    NCI Thesaurus Property C25331
      ...
      There are 4 more alias. Click to show them.
    NCI Thesaurus Property-2 C25388
    UMLS 2011AA Property C1947913
    NCI Thesaurus ValueDomain C13717
    UMLS 2011AA ValueDomain C1515974
    Codelistitems  
      Common Iliac(Common iliac)
      External Iliac(External iliac)
      Hypogastric(Hypogastric)
      Internal Iliac(Internal iliac)
      Other Specify(Other)
      Para-aortic(Para-aortic)
      ...
      There are 1 more items on this list. Click to show them.
    Name DistantMetastasisProgressionInd-3
    Question Has the patient been diagnosed with a distant metastatic progression that has not been previously reported
    Datatype boolean
    Aliases:  
    NCI Thesaurus ValueDomain C38148
    UMLS 2011AA ValueDomain C1512699
    NCI Thesaurus Property C25331
    NCI Thesaurus ObjectClass C25321
    UMLS 2011AA ObjectClass C0443203
      ...
      There are 2 more alias. Click to show them.
    NCI Thesaurus ObjectClass-2 C19151
    UMLS 2011AA ObjectClass-2 C0027627
    Name Date of Neoplasm distal recurrence
    Question Date of First Distant Progression
    Datatype date
    Aliases:  
    NCI Thesaurus ValueDomain C25164
    UMLS CUI-1 C0027627
    NCI Thesaurus ObjectClass C25331
    NCI Thesaurus ValueDomain-2 C25509
    UMLS CUI-2 C0011008
      ...
      There are 1 more alias. Click to show them.
    NCI Thesaurus Property C25275
    Name ProgressionSite,FirstDistant
    Question Progression Site, First Distant
    Datatype text
    Aliases:  
    Codelistitems  
      Bone(bone)
      Central Nervous System Or Brain(central nervous system/brain)
      Distant Lymph Nodes(distant nodes)
      Liver(liver)
      Lung(lung)
      ...
      There are 4 more items on this list. Click to show them.
      Other, Specify(other)
      Peritoneum(peritoneum)
      Pleura(pleura)
      Skin(skin)
    Name LymphNodes,DistantLocation
    Question Distant Nodes, specify
    Datatype text
    Aliases:  
    Name Sitesofprogression,OtherSpecify
    Question Sites of progression, Other Specify
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25685
    UMLS 2011AA ValueDomain C1521902
    NCI Thesaurus ValueDomain-2 C17649
    UMLS 2011AA ValueDomain-2 C0205394
    Name Sitesofprogression,OtherSpecify
    Question Sites of progression, Other Specify
    Datatype text
    Aliases:  
    NCI Thesaurus ValueDomain C25685
    UMLS 2011AA ValueDomain C1521902
    NCI Thesaurus ValueDomain-2 C17649
    UMLS 2011AA ValueDomain-2 C0205394

    Bladder/urothelial: Notice Of New Primary

    Name: BLADDER/UROTHELIAL: NOTICE OF NEW PRIMARY
    Description: Bladder/urothelial: Notice Of New Primary

    Name NewPrimaryCancerInd
    Question New Primary Cancer Ind
    Datatype text
    Aliases:  
    Codelistitems  
      No(NO)
      Unknown(UNKNOWN)
      Yes(YES)
    Name NewPrimaryCancerDate
    Question New Primary Cancer Date
    Datatype date
    Aliases:  
    NCI Thesaurus ValueDomain C25164
    UMLS 2011AA ValueDomain C0011008
    Name NewPrimarySite
    Question New Primary Site
    Datatype text
    Aliases:  

    Bladder/urothelial: Long-term Toxicity

    Name: BLADDER/UROTHELIAL: LONG-TERM TOXICITY
    Description: Bladder/urothelial: Long-term Toxicity

    Name LateAdverseEventInd
    Question Late Adverse Event Ind
    Datatype text
    Aliases:  
    Codelistitems  
      No(NO)
      Unknown(UNKNOWN)
      Yes(YES)
    Name LateAdverseEventTerm
    Question Late Adverse Event Term
    Datatype text
    Aliases:  
    Codelistitems  
      Use Rtog/eortc Grading System (see Ctc Version 2.0. Http://ctep.info.nih.gov/ctc3/ctc.htm).(Use RTOG/EORTC grading system (See CTC version 2.0. http://ctep.info.nih.gov/CTC3/ctc.htm).)
    Name LateAdverseEventGrade
    Question Late Adverse Event Grade
    Datatype text
    Aliases:  
    Name LateAdverseEventOnsetDate
    Question Late Adverse Event Onset Date
    Datatype date
    Aliases:  

    Allows Documentation Of Any Additional Cooments

    Name: Comments
    Description: Allows Documentation Of Any Additional Cooments

    Name Comments
    Question Comments
    Datatype text
    Aliases:  

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8. Miscellaneous

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  6. The rights granted under, and the subject matter referenced, in this License were drafted utilizing the terminology of the Berne Convention for the Protection of Literary and Artistic Works (as amended on September 28, 1979), the Rome Convention of 1961, the WIPO Copyright Treaty of 1996, the WIPO Performances and Phonograms Treaty of 1996 and the Universal Copyright Convention (as revised on July 24, 1971). These rights and subject matter take effect in the relevant jurisdiction in which the License terms are sought to be enforced according to the corresponding provisions of the implementation of those treaty provisions in the applicable national law. If the standard suite of rights granted under applicable copyright law includes additional rights not granted under this License, such additional rights are deemed to be included in the License; this License is not intended to restrict the license of any rights under applicable law.