ID

1002

Beskrivning

Bilateral Surgery Form (Form 24-BC) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=01617880-D901-0B38-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=01617880-D901-0B38-E044-0003BA3F9857

Nyckelord

Versioner (2)
  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
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26 augusti 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Pathology - Bilateral Surgery Form (Form 24-BC) - 2408466v1.0

Engelsk

SURGERY FORM (Form 24-C) Instructions: This form is to be completed and submitted one month after final surgery. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 Formulär  
Ccrr Module For Surgery Form (form 24-c)
Beskrivning

Ccrr Module For Surgery Form (form 24-c)

Patient ID No. (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Patient Initials (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

PatientInitialsName

Datatyp

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
Patient's Date of Birth (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

PatientBirthDate

Datatyp

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Participating Center/Affiliate
Beskrivning

ParticipatingCenter/Affiliate

Datatyp

text

Center Code
Beskrivning

ParticipatingGroupCode

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
This form is being completed for
Beskrivning

BreastSideAssessmentSite

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus Property
C25306
UMLS 2011AA Property
C0441987
Date of Initial Pathologic Diagnosis (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

InitialDiagnosisDate

Datatyp

date

Type (LTM = less than mastectomy)
Beskrivning

SurgicalProcedureBreastNeoplasmPerformedType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C2910
UMLS 2011AA Property
C0042875
Other, (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

Other,

Datatyp

text

Surgery Date (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

SurgeryDate

Datatyp

date

PATHOLOGICAL FINDINGS (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

PATHOLOGICALFINDINGS

Datatyp

text

Was sentinel node biopsy performed? (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

SentinelNodeBiopsyInd

Datatyp

text

Sentinel Node Biopsy Date (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

SentinelNodeBiopsyDate

Datatyp

date

Was axillary dissection performed? (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

AxillaryDissectionInd

Datatyp

text

Date of axillary dissection (CCRR MODULE FOR Surgery Form Form 24-C)
Beskrivning

AxillaryDissectionDate

Datatyp

date

Investigator Signature (/Designee)
Beskrivning

InvestigatorSignatureText

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beskrivning

InvestigatorSignatureDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
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Similar models

SURGERY FORM (Form 24-C) Instructions: This form is to be completed and submitted one month after final surgery. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Ccrr Module For Surgery Form (form 24-c)
PatientStudyID,CoordinatingGroup
Item
Patient ID No. (CCRR MODULE FOR Surgery Form Form 24-C)
text
PatientInitialsName
Item
Patient Initials (CCRR MODULE FOR Surgery Form Form 24-C)
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)
PatientBirthDate
Item
Patient's Date of Birth (CCRR MODULE FOR Surgery Form Form 24-C)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Item
This form is being completed for
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25306 (NCI Thesaurus Property)
C0441987 (UMLS 2011AA Property)
CL.1
Code List
This form is being completed for
CL Item
Left Breast/side (Left breast/side)
CL Item
Right Breast/side (Right breast/side)
InitialDiagnosisDate
Item
Date of Initial Pathologic Diagnosis (CCRR MODULE FOR Surgery Form Form 24-C)
date
Item
Type (LTM = less than mastectomy)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C2910 (NCI Thesaurus Property)
C0042875 (UMLS 2011AA Property)
CL.2
Code List
Type (LTM = less than mastectomy)
CL Item
Core Biopsy (Core biopsy)
C15680 (NCI Thesaurus)
C1318309 (UMLS 2011AA)
CL Item
Fine Needle Aspiration (Fine needle aspiration)
CL Item
Ltm: Lump Excision/complete Local Excision (LTM: lump excision/complete local excision)
CL Item
Ltm: Partial Mastectomy/quadrantectomy (LTM: partial mastectomy/quadrantectomy)
CL Item
Ltm: Re-excision For Unclear Or Positive Margins (LTM: re-excision for unclear or positive margins)
CL Item
Ltm: Subcutaneous Mastectomy (LTM: subcutaneous mastectomy)
CL Item
Ltm: Subtotal Mastectomy (LTM: subtotal mastectomy)
CL Item
Mastectomy (Mastectomy)
C15277 (NCI Thesaurus)
C0024881 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Other Biopsy (Other biopsy)
Other,
Item
Other, (CCRR MODULE FOR Surgery Form Form 24-C)
text
SurgeryDate
Item
Surgery Date (CCRR MODULE FOR Surgery Form Form 24-C)
date
Item
PATHOLOGICAL FINDINGS (CCRR MODULE FOR Surgery Form Form 24-C)
text
CL.3
Code List
PATHOLOGICAL FINDINGS (CCRR MODULE FOR Surgery Form Form 24-C)
CL Item
No Malignancy (No malignancy)
CL Item
Suspicious For Malignancy (Suspicious for malignancy)
CL Item
Malignant Cells On Fna (Malignant cells on FNA)
CL Item
In Situ Without Invasion (IN SITU without invasion)
CL Item
Invasive Cancer (Invasive cancer)
Item
Was sentinel node biopsy performed? (CCRR MODULE FOR Surgery Form Form 24-C)
text
CL.4
Code List
Was sentinel node biopsy performed? (CCRR MODULE FOR Surgery Form Form 24-C)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SentinelNodeBiopsyDate
Item
Sentinel Node Biopsy Date (CCRR MODULE FOR Surgery Form Form 24-C)
date
Item
Was axillary dissection performed? (CCRR MODULE FOR Surgery Form Form 24-C)
text
CL.5
Code List
Was axillary dissection performed? (CCRR MODULE FOR Surgery Form Form 24-C)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AxillaryDissectionDate
Item
Date of axillary dissection (CCRR MODULE FOR Surgery Form Form 24-C)
date
InvestigatorSignatureText
Item
Investigator Signature (/Designee)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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