ID

10075

Beschreibung

E5202 Leucovorin Supplemental Form Oxaliplatin, Leucovorin, and Fluorouracil With or Without Bevacizumab in Treating Patients Who Have Undergone Surgery for Stage II Colon Cancer NCT00217737 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=604FA9F1-CB9F-41AD-E040-BB89AD433F0D

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=604FA9F1-CB9F-41AD-E040-BB89AD433F0D

Stichworte

Versionen (3)
  1. 27.08.12 27.08.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 23.03.15 23.03.15 - Martin Dugas
Hochgeladen am

23. März 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT00217737

Englisch

INSTRUCTIONS: Complete this form at the end of each cycle during the Leucovorin shortage.

1 Formulare  
Header
Beschreibung

Header

Alias
UMLS CUI-1
C1320722
ECOG Protocol Number
Beschreibung

Protocol Number ECOG

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Patient ID
Beschreibung

Patient ID ECOG

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
DCI Name
Beschreibung

Generic drug form

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C3242750
NCI Thesaurus Property
C19464
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus ObjectClass-2
C25452
Registration Step
Beschreibung

Registration Number

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1514821
NCI Thesaurus ObjectClass
C25646
UMLS CUI-2
C0237753
NCI Thesaurus Property
C16154
NCI Thesaurus ValueDomain-2
C16154
Patient Initials (Last, First)
Beschreibung

Patient Initials

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Participating Group Protocol Number
Beschreibung

Study Number Participating Group

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Institution/Affiliate
Beschreibung

Institution Name

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Participating Group Patient ID
Beschreibung

Trial subject ID Participating Group

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Please mark an 'X' if data have been amended
Beschreibung

Please mark an 'X' if data have been amended

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI-1
C0680532
Date data amended (s)
Beschreibung

Data amended date

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
UMLS CUI-2
C0011008
NCI Thesaurus Property
C25416
NCI Thesaurus ValueDomain-2
C25367
Reporting Period (1 cycle = 2 weeks)
Beschreibung

Clinical Trial Period

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C2347804
NCI Thesaurus ObjectClass
C25214
NCI Thesaurus Property
C25616
NCI Thesaurus ObjectClass-2
C25651
Investigator Signature
Beschreibung

Investigator Signature

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
Investigator Signature Date
Beschreibung

Investigator Signature Date

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
UMLS CUI-2
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C17089
Therapy
Beschreibung

Therapy

Alias
UMLS CUI-1
C0087111
Was Leucovorin administered
Beschreibung

ChemotherapyLeucovorinCalciumAdministeredInd-2

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus ObjectClass
C15632
NCI Thesaurus Property
C607
NCI Thesaurus Property-2
C25382
UMLS CUI-1
C0023413
If (racemic) Leucovorin was not given, please specify why
Beschreibung

ChemotherapyLeucovorinCalciumNegationAdministeredReason

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C15632
NCI Thesaurus Property
C25594
NCI Thesaurus Property-2
C607
NCI Thesaurus Property-3
C25382
NCI Thesaurus ValueDomain
C25638
Was Levoleucovorin substituted
Beschreibung

ChemotherapyLeucovorinCalciumSubstitutionAdministeredIndicator

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C15632
NCI Thesaurus Property
C607
NCI Thesaurus Property-2
C25382
NCI Thesaurus Property-3
C54071
NCI Thesaurus ValueDomain
C25180
dose administered (If yes,)
Beschreibung

ChemotherapyLeucovorinCalciumSubstitutionAdministeredMilligramDose

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C15632
NCI Thesaurus Property
C607
NCI Thesaurus Property-2
C25382
NCI Thesaurus Property-3
C54071
NCI Thesaurus ValueDomain
C28253
NCI Thesaurus ValueDomain-2
C25488
UMLS CUI-1
C0023413
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Ähnliche Modelle

INSTRUCTIONS: Complete this form at the end of each cycle during the Leucovorin shortage.

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Generic drug form
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
Registration Number
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Patient Initials
Item
Patient Initials (Last, First)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Data amended
Item
Please mark an 'X' if data have been amended
boolean
C25704 (NCI Thesaurus ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
Data amended date
Item
Date data amended (s)
date
C25164 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item
Reporting Period (1 cycle = 2 weeks)
text
C25284 (NCI Thesaurus ValueDomain)
C2347804 (UMLS CUI-1)
C25214 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C25651 (NCI Thesaurus ObjectClass-2)
CL.1
Code List
Reporting Period (1 cycle = 2 weeks)
CL Item
Cycle 1 (Cycle 1)
CL Item
Cycle 10 (Cycle 10)
CL Item
Cycle 11 (Cycle 11)
CL Item
Cycle 12 (Cycle 12)
CL Item
Cycle 2 (Cycle 2)
CL Item
Cycle 3 (Cycle 3)
CL Item
Cycle 4 (Cycle 4)
CL Item
Cycle 5 (Cycle 5)
CL Item
Cycle 6 (Cycle 6)
CL Item
Cycle 7 (Cycle 7)
CL Item
Cycle 8 (Cycle 8)
CL Item
Cycle 9 (Cycle 9)
Investigator Signature
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
Investigator Signature Date
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
Item Group
Therapy
C0087111 (UMLS CUI-1)
Leucovorin
Item
Was Leucovorin administered
boolean
C38147 (NCI Thesaurus ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C607 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C0023413 (UMLS CUI-1)
Item
If (racemic) Leucovorin was not given, please specify why
text
C15632 (NCI Thesaurus ObjectClass)
C25594 (NCI Thesaurus Property)
C607 (NCI Thesaurus Property-2)
C25382 (NCI Thesaurus Property-3)
C25638 (NCI Thesaurus ValueDomain)
CL.3
Code List
If (racemic) Leucovorin was not given, please specify why
CL Item
Drug Not Available (Drug not available)
CL Item
Toxicity (Toxicity)
C27990 (NCI Thesaurus)
C0600688 (UMLS 2011AA)
Item
Was Levoleucovorin substituted
text
C15632 (NCI Thesaurus ObjectClass)
C607 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C54071 (NCI Thesaurus Property-3)
C25180 (NCI Thesaurus ValueDomain)
CL.4
Code List
Was Levoleucovorin substituted
CL Item
Not Available (N/A)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Leucovorin dose
Item
dose administered (If yes,)
float
C15632 (NCI Thesaurus ObjectClass)
C607 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C54071 (NCI Thesaurus Property-3)
C28253 (NCI Thesaurus ValueDomain)
C25488 (NCI Thesaurus ValueDomain-2)
C0023413 (UMLS CUI-1)
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