ID

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

DOI

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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
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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)
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