Inglés

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 formularios  
CALGB Information
Descripción

CALGB Information

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

Amended data?
Descripción

Amendeddata?

Tipo de datos

text

Patient clinical trial data
Descripción

Patient clinical trial data

Patient's Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroup

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Adjunct

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientNo.

Tipo de datos

text

Radiation Treatment
Descripción

Radiation Treatment

Has the patient received adjuvant therapy? (prior to diagnosis of recurrence or second primary cancer)
Descripción

Hasthepatientreceivedadjuvanttherapy?

Tipo de datos

text

Date adjuvant radiation therapy started (M)
Descripción

AdjuvantRTBeginDate

Tipo de datos

date

Date adjuvant radiation therapy ended (M)
Descripción

AdjuvantRTEndDate

Tipo de datos

date

Nature of radiotherapy (mark one box with an X)
Descripción

Natureofradiotherapy

Tipo de datos

text

Completed By (Print or Type Name)
Descripción

CompletedBy

Tipo de datos

text

Date Completed
Descripción

DateCompleted

Tipo de datos

date

Ccrr Module For Calgb: Adjuvant Radiotherapy Report Form
Descripción

Ccrr Module For Calgb: Adjuvant Radiotherapy Report Form

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Similar models

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
CALGB Information
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Patient clinical trial data
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Radiation Treatment
Item
Has the patient received adjuvant therapy? (prior to diagnosis of recurrence or second primary cancer)
text
CL.2
Code List
Has the patient received adjuvant therapy? (prior to diagnosis of recurrence or second primary cancer)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AdjuvantRTBeginDate
Item
Date adjuvant radiation therapy started (M)
date
AdjuvantRTEndDate
Item
Date adjuvant radiation therapy ended (M)
date
Item
Nature of radiotherapy (mark one box with an X)
text
CL.3
Code List
Nature of radiotherapy (mark one box with an X)
CL Item
In-breast Radiotherapy Following Breast-conserving Surgery (In-breast radiotherapy following breast-conserving surgery)
CL Item
In-breast And Regional Radiotherapy Following Breast-conserving Surgery (In-breast and regional radiotherapy following breast-conserving surgery)
CL Item
Any Post-mastectomy Radiotherapy (Any post-mastectomy radiotherapy)
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed
date
Item Group
Ccrr Module For Calgb: Adjuvant Radiotherapy Report Form
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