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10092

Description

ECOG-E1505 Follow Up Smoking Survey Chemotherapy With or Without Bevacizumab in Treating Patients With Stage IB, Stage II, or Stage IIIA Non-Small Lung Cancer That Was Removed By Surgery NCT00324805 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0745B0C2-1A2A-5046-E044-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0745B0C2-1A2A-5046-E044-0003BA3F9857

Mots-clés

Versions (5)
  1. 19/09/2012 19/09/2012 -
  2. 11/08/2014 11/08/2014 - Martin Dugas
  3. 11/08/2014 11/08/2014 - Martin Dugas
  4. 09/01/2015 09/01/2015 - Martin Dugas
  5. 25/03/2015 25/03/2015 - Martin Dugas
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25 mars 2015

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Creative Commons BY-NC 3.0 Legacy
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    Lung Cancer Smoking Survey NCT00324805

    Anglais

    INSTRUCTIONS: Use this form to capture the first occurrence of non-protocol anti-tumor therapy per registration step

    1 Formulaires  
    Header
    Description

    Header

    ECOG Protocol Number
    Description

    Protocol Number ECOG

    Type de données

    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
    Description

    Patient ID ECOG

    Type de données

    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
    Description

    Generic drug form

    Type de données

    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
    Description

    Registration Number

    Type de données

    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)
    Description

    Patient Initials

    Type de données

    text

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

    Study Number Participating Group

    Type de données

    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
    Description

    Institution Name

    Type de données

    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
    Description

    Trial subject ID Participating Group

    Type de données

    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 (Please circle amended data in red.)
    Description

    Data amended

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Date data amended (M D Y)
    Description

    Data amended date

    Type de données

    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
    Investigator Signature
    Description

    Investigator Signature

    Type de données

    text

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

    Investigator Signature Date

    Type de données

    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
    Smoking status
    Description

    Smoking status

    Alias
    UMLS CUI-1
    C1519386
    Reporting Period (since registration Both Arms)
    Description

    Clinical Trial Period

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C2347804
    NCI Thesaurus ObjectClass
    C25214
    NCI Thesaurus Property
    C25616
    NCI Thesaurus ObjectClass-2
    C25651
    Date data obtained
    Description

    DataObtainedDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C52349
    UMLS CUI-1
    C1317250
    Does the patient currently smoke cigarettes
    Description

    Does the patient currently smoke cigarettes

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    NCI Thesaurus Property
    C25471
    NCI Thesaurus ObjectClass
    C17934
    NCI Metathesaurus Property
    C0449865
    UMLS CUI-1
    C3241966
    Which of the following applies to the patient's smoking habit after diagnosis of his/her lung cancer
    Description

    SmokingPostDiagnosisStatus

    Type de données

    text

    Alias
    NCI Thesaurus Property
    C38008
    NCI Thesaurus Property-2
    C15220
    NCI Thesaurus ObjectClass
    C17934
    NCI Thesaurus ValueDomain
    C25688
    UMLS CUI-1
    C0687676
    UMLS CUI-2
    C0011900
    UMLS CUI-3
    C0453996
    Date Patient Stopped Smoking (If patient stopped smoking:)
    Description

    SmokingDiscontinuedDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus Property
    C25484
    NCI Thesaurus ObjectClass
    C17934
    UMLS CUI-1
    C3650858
    On average how many cigarettes per day does the patient smoke
    Description

    Smoker amount smoked

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C17934
    UMLS CUI-1
    C1608325
    NCI Thesaurus Property
    C25471
    NCI Metathesaurus Property
    C0449865
    NCI Thesaurus ValueDomain
    C25473
    NCI Thesaurus ValueDomain-2
    C25515
    Nic Alert Test Result
    Description

    Nic Alert Test Result

    NicAlert Test Performed
    Description

    LaboratoryProcedureCotinineResultInd-2

    Type de données

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    NCI Thesaurus Property
    C20200
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus Property-2
    C70941
    UMLS CUI-1
    C0010194
    Cotinine Concentration Level
    Description

    LaboratoryProcedureCotinineResultStatus

    Type de données

    text

    Alias
    NCI Thesaurus Property
    C20200
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus ValueDomain
    C25688
    NCI Thesaurus Property-2
    C70941
    UMLS CUI-1
    C0010194
    Date of Nic Alert Test
    Description

    LaboratoryProcedureCotinineResultDate

    Type de données

    date

    Unités de mesure
    • M D Y
    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus Property
    C20200
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus Property-2
    C70941
    UMLS CUI-1
    C0010194
    UMLS CUI-2
    C0011008
    M D Y
    Retour au début de la page

    Similar models

    INSTRUCTIONS: Use this form to capture the first occurrence of non-protocol anti-tumor therapy per registration step

    1 Formulaires
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Header
    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 (Please circle amended data in red.)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Data amended date
    Item
    Date data amended (M D Y)
    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)
    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
    Smoking status
    C1519386 (UMLS CUI-1)
    Item
    Reporting Period (since registration Both Arms)
    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 (since registration Both Arms)
    CL Item
    3 Months Post Registration (3 Months Post Registration)
    CL Item
    6 Months Post Registration (6 Months Post Registration)
    CL Item
    9 Months Post Registration (9 Months Post Registration)
    CL Item
    12 Months Post Registration (12 Months Post Registration)
    Collection Date
    Item
    Date data obtained
    date
    C25164 (NCI Thesaurus ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C52349 (NCI Thesaurus Property)
    C1317250 (UMLS CUI-1)
    Item
    Does the patient currently smoke cigarettes
    text
    C25180 (NCI Thesaurus ValueDomain)
    C25471 (NCI Thesaurus Property)
    C17934 (NCI Thesaurus ObjectClass)
    C0449865 (NCI Metathesaurus Property)
    C3241966 (UMLS CUI-1)
    CL.2
    Code List
    Does the patient currently smoke cigarettes
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS CUI-1)
    CL Item
    Patient Refused To Answer (Patient Refused to Answer)
    C1705116 (UMLS CUI-1)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS CUI-1)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS CUI-1)
    Item
    Which of the following applies to the patient's smoking habit after diagnosis of his/her lung cancer
    text
    C38008 (NCI Thesaurus Property)
    C15220 (NCI Thesaurus Property-2)
    C17934 (NCI Thesaurus ObjectClass)
    C25688 (NCI Thesaurus ValueDomain)
    C0687676 (UMLS CUI-1)
    C0011900 (UMLS CUI-2)
    C0453996 (UMLS CUI-3)
    CL.3
    Code List
    Which of the following applies to the patient's smoking habit after diagnosis of his/her lung cancer
    CL Item
    No Change In Smoking Habits. Patient Smokes The Same Amount Now In Comparison To Before Diagnosis (No change in smoking habits. Patient smokes the same amount now in comparison to before diagnosis)
    CL Item
    No Change In Smoking Habits. Patient Still Does Not Smoke (No change in smoking habits. Patient still does not smoke)
    CL Item
    Patient Smokes Fewer Cigarettes Now (Patient smokes fewer cigarettes now)
    CL Item
    Patient Smokes More Cigarettes Now (Patient smokes more cigarettes now)
    CL Item
    Patient Stopped Smoking (Patient stopped smoking)
    Smoking cessation date
    Item
    Date Patient Stopped Smoking (If patient stopped smoking:)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C25484 (NCI Thesaurus Property)
    C17934 (NCI Thesaurus ObjectClass)
    C3650858 (UMLS CUI-1)
    Item
    On average how many cigarettes per day does the patient smoke
    text
    C17934 (NCI Thesaurus ObjectClass)
    C1608325 (UMLS CUI-1)
    C25471 (NCI Thesaurus Property)
    C0449865 (NCI Metathesaurus Property)
    C25473 (NCI Thesaurus ValueDomain)
    C25515 (NCI Thesaurus ValueDomain-2)
    CL.4
    Code List
    On average how many cigarettes per day does the patient smoke
    CL Item
    No Cigarettes (No cigarettes)
    CL Item
    Fewer Than 10 Cigarettes (Fewer than 10 cigarettes)
    CL Item
    10 To 20 Cigarettes (10 to 20 cigarettes)
    CL Item
    More Than 20 Cigarettes (more than 20 cigarettes)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item Group
    Nic Alert Test Result
    NicAlert Test Performed
    Item
    NicAlert Test Performed
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C20200 (NCI Thesaurus Property)
    C25294 (NCI Thesaurus ObjectClass)
    C70941 (NCI Thesaurus Property-2)
    C0010194 (UMLS CUI-1)
    Item
    Cotinine Concentration Level
    text
    C20200 (NCI Thesaurus Property)
    C25294 (NCI Thesaurus ObjectClass)
    C25688 (NCI Thesaurus ValueDomain)
    C70941 (NCI Thesaurus Property-2)
    C0010194 (UMLS CUI-1)
    CL.6
    Code List
    Cotinine Concentration Level
    CL Item
    Level 0 (Level 0)
    CL Item
    Level 1 (Level 1)
    CL Item
    Level 2 (Level 2)
    CL Item
    Level 3 (Level 3)
    CL Item
    Level 4 (Level 4)
    CL Item
    Level 5 (Level 5)
    CL Item
    Level 6 (Level 6)
    Date of Nic Alert Test
    Item
    Date of Nic Alert Test
    date
    C25164 (NCI Thesaurus ValueDomain)
    C20200 (NCI Thesaurus Property)
    C25294 (NCI Thesaurus ObjectClass)
    C70941 (NCI Thesaurus Property-2)
    C0010194 (UMLS CUI-1)
    C0011008 (UMLS CUI-2)
    Retour au début de la page 

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