ID

10285

Beschreibung

E2100 On-Study Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC34564B-C2DB-255C-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC34564B-C2DB-255C-E034-0003BA12F5E7

Stichworte

Versionen (2)
  1. 27.08.12 27.08.12 -
  2. 23.05.15 23.05.15 -
Hochgeladen am

23. Mai 2015

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

E2100 On-Study Form (E2100)

Englisch

Form No. 1575

1 Formulare  
  1. StudyEvent: E2100 On-Study Form (E2100)
    1. Form No. 1575
ECOG Clinical trial administrative data
Beschreibung

ECOG Clinical trial administrative data

ECOG Protocol No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Patient ID
Beschreibung

ECOGPatientID

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C16154
UMLS 2011AA ValueDomain-2
C1704379
Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Participating Group Patient ID
Beschreibung

ParticipatingGroupPatientID

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Are data amended?
Beschreibung

AmendedDataInd

Datentyp

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient Characteristics
Beschreibung

Patient Characteristics

Menopausal Status (Choose one:)
Beschreibung

MenopausalStatus

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Advanced Disease Description
Beschreibung

Advanced Disease Description

ER Status (most recent)
Beschreibung

ERStatus

Datentyp

text

Receptor Status Timing (most recent)
Beschreibung

ReceptorStatusTiming

Datentyp

text

ER Timing, Other, Specify
Beschreibung

ERTiming,Other

Datentyp

text

PgR Status (most recent)
Beschreibung

PgRStatus

Datentyp

text

PgR Timing, Other, Specify
Beschreibung

PgRTiming,Other

Datentyp

text

Her2/Neu expression status by immunohistochemistry (Choose one:)
Beschreibung

Her2/Neuexpressionstatusbyimmunohistochemistry

Datentyp

text

Her2/Neu expression status by FISH (Choose one:)
Beschreibung

Her2/NeuexpressionstatusbyFISH

Datentyp

text

Date of Initial Diagnosis of Primary Tumor (M D Y)
Beschreibung

FirstPositiveBiopsyDate

Datentyp

date

Date Recurrent, Progressive, or Metastatic Disease First Diagnosed (M D Y)
Beschreibung

DateRecurrent,Progressive,orMetastaticDiseaseFirstDiagnosed

Datentyp

date

Site(s) Of Involvement
Beschreibung

Site(s) Of Involvement

Local-regional (sites of involvement) (Circle the involved local-regional sites listed in below:)
Beschreibung

Local-regional(sitesofinvolvement)

Datentyp

text

Ipsilateral supraclavicular nodes (sites of involvement)
Beschreibung

Ipsilateralsupraclavicularnodes(sitesofinvolvement)

Datentyp

boolean

Opposite breast (sites of involvement)
Beschreibung

Oppositebreast(sitesofinvolvement)

Datentyp

boolean

Distant nodes (sites of involvement)
Beschreibung

Distantnodes(sitesofinvolvement)

Datentyp

boolean

Distant skin/subcutaneous tissue (sites of involvement)
Beschreibung

Distantskin/subcutaneoustissue(sitesofinvolvement)

Datentyp

boolean

Bone (sites of involvement)
Beschreibung

Bone(sitesofinvolvement)

Datentyp

boolean

Bone marrow (sites of involvement)
Beschreibung

Bonemarrow(sitesofinvolvement)

Datentyp

boolean

Lung (sites of involvement)
Beschreibung

Lung(sitesofinvolvement)

Datentyp

boolean

Liver (sites of involvement)
Beschreibung

Liver(sitesofinvolvement)

Datentyp

boolean

Pleura (sites of involvement)
Beschreibung

Pleura(sitesofinvolvement)

Datentyp

boolean

Brain (sites of involvement)
Beschreibung

Brain(sitesofinvolvement)

Datentyp

boolean

Other CNS (sites of involvement)
Beschreibung

OtherCNS(sitesofinvolvement)

Datentyp

boolean

First Other, specify (sites of involvement)
Beschreibung

FirstOther,specify(sitesofinvolvement)

Datentyp

boolean

Second Other, specify (sites of involvement)
Beschreibung

SecondOther,specify(sitesofinvolvement)

Datentyp

boolean

First Other, specify
Beschreibung

FirstOther,specify

Datentyp

text

Second Other, specify
Beschreibung

SecondOther,specify

Datentyp

text

Prior Systemic Therapy
Beschreibung

Prior Systemic Therapy

Prior Adjuvant Hormonal Therapy? (do not include steroids given with chemotherapy)
Beschreibung

PriorAdjuvantHormonalTherapyInd

Datentyp

boolean

Prior Metastatic/Recurrent Hormonal Therapy? (do not include steroids given with chemotherapy)
Beschreibung

PriorMetastatic/RecurrentHormonalTherapyInd

Datentyp

boolean

Prior Adjuvant Chemotherapy? (include pre-op chemotherapy at diagnosis)
Beschreibung

PriorAdjuvantChemotherapyInd

Datentyp

boolean

Prior Chemotherapy for Metastasis or Recurrence?
Beschreibung

PriorMetastatic/RecurrentChemotherapyInd

Datentyp

boolean

Prior Adjuvant High Dose Chemotherapy/Autologous Stem Cell Transplant?
Beschreibung

PriorAdjuvantHighDoseChemotherapy/AutologousStemCellTransplant?

Datentyp

boolean

Prior High Dose Chemotherapy/Autologous Stem Cell Transplant for Metastasis or Recurrence?
Beschreibung

PriorHighDoseChemotherapy/AutologousStemCellTransplantforMetastasisorRecurrence?

Datentyp

boolean

Prior Adjuvant Immunotherapy?
Beschreibung

PriorAdjuvantImmunotherapyInd

Datentyp

boolean

Prior Immunotherapy for Metastasis or Recurrence?
Beschreibung

PriorMetastatic/RecurrentImmunotherapyInd

Datentyp

boolean

Prior Adjuvant Other Therapy?
Beschreibung

PriorAdjuvantOtherTherapyInd

Datentyp

boolean

Prior Metastatic/Recurrent Other Therapy?
Beschreibung

PriorMetastatic/RecurrentOtherTherapyInd

Datentyp

boolean

Prior Systemic Regimens
Beschreibung

Prior Systemic Regimens

Prior Treatment Regimen Name(s)
Beschreibung

PriorTreatmentRegimenName(s)

Datentyp

text

Prior Treatment Regimen Start Date (M/D/Y)
Beschreibung

PriorTreatmentRegimenBeginDate

Datentyp

date

Prior Treatment Regimen End Date (M/D/Y)
Beschreibung

PriorTreatmentRegimenEndDate

Datentyp

date

Prior Treatment Regimen Type
Beschreibung

PriorTreatmentRegimenType

Datentyp

text

Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beschreibung

Date

Datentyp

text

Ccrr Module For E2100 On-study Form (e2100)
Beschreibung

Ccrr Module For E2100 On-study Form (e2100)

Zum Seitenanfang zurückkehren

Ähnliche Modelle

Form No. 1575

1 Formulare
  1. StudyEvent: E2100 On-Study Form (E2100)
    1. Form No. 1575
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
ECOG Clinical trial administrative data
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain-2)
C1704379 (UMLS 2011AA ValueDomain-2)
Patient'sName
Item
Patient's Name
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
AmendedDataInd
Item
Are data amended?
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Patient Characteristics
Item
Menopausal Status (Choose one:)
text
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.2
Code List
Menopausal Status (Choose one:)
CL Item
Pre (Pre)
CL Item
Post (Post)
C38008 (NCI Thesaurus)
C0687676 (UMLS 2011AA)
CL Item
Above Categories Not Applicable And Age <50 (Above categories not applicable AND Age <50)
CL Item
Above Categories Not Applicable And Age >= 50 (Above categories not applicable AND Age >= 50)
Item Group
Advanced Disease Description
Item
ER Status (most recent)
text
CL.3
Code List
ER Status (most recent)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Receptor Status Timing (most recent)
text
CL.6
Code List
Receptor Status Timing (most recent)
CL Item
Initial Diagnosis (Initial Diagnosis)
CL Item
At Recurrence (At Recurrence)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
ERTiming,Other
Item
ER Timing, Other, Specify
text
Item
PgR Status (most recent)
text
CL.5
Code List
PgR Status (most recent)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PgRTiming,Other
Item
PgR Timing, Other, Specify
text
Item
Her2/Neu expression status by immunohistochemistry (Choose one:)
text
CL.7
Code List
Her2/Neu expression status by immunohistochemistry (Choose one:)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1+ (1+)
CL Item
2+ (2+)
CL Item
3+ (3+)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
Item
Her2/Neu expression status by FISH (Choose one:)
text
CL.8
Code List
Her2/Neu expression status by FISH (Choose one:)
CL Item
Non-amplified (Non-amplified)
CL Item
Amplified (Amplified)
CL Item
8 (8)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
FirstPositiveBiopsyDate
Item
Date of Initial Diagnosis of Primary Tumor (M D Y)
date
DateRecurrent,Progressive,orMetastaticDiseaseFirstDiagnosed
Item
Date Recurrent, Progressive, or Metastatic Disease First Diagnosed (M D Y)
date
Item Group
Site(s) Of Involvement
Item
Local-regional (sites of involvement) (Circle the involved local-regional sites listed in below:)
text
CL.23
Code List
Local-regional (sites of involvement) (Circle the involved local-regional sites listed in below:)
CL Item
ipsilateraly breast (ipsilateraly breast)
CL Item
chest wall (chest wall)
CL Item
axillary, internal mammary and infraclavicular nodes (axillary, internal mammary and infraclavicular nodes)
CL Item
local regional skin and subcutaneous tissue (local regional skin and subcutaneous tissue)
Ipsilateralsupraclavicularnodes(sitesofinvolvement)
Item
Ipsilateral supraclavicular nodes (sites of involvement)
boolean
Oppositebreast(sitesofinvolvement)
Item
Opposite breast (sites of involvement)
boolean
Distantnodes(sitesofinvolvement)
Item
Distant nodes (sites of involvement)
boolean
Distantskin/subcutaneoustissue(sitesofinvolvement)
Item
Distant skin/subcutaneous tissue (sites of involvement)
boolean
Bone(sitesofinvolvement)
Item
Bone (sites of involvement)
boolean
Bonemarrow(sitesofinvolvement)
Item
Bone marrow (sites of involvement)
boolean
Lung(sitesofinvolvement)
Item
Lung (sites of involvement)
boolean
Liver(sitesofinvolvement)
Item
Liver (sites of involvement)
boolean
Pleura(sitesofinvolvement)
Item
Pleura (sites of involvement)
boolean
Brain(sitesofinvolvement)
Item
Brain (sites of involvement)
boolean
OtherCNS(sitesofinvolvement)
Item
Other CNS (sites of involvement)
boolean
FirstOther,specify(sitesofinvolvement)
Item
First Other, specify (sites of involvement)
boolean
SecondOther,specify(sitesofinvolvement)
Item
Second Other, specify (sites of involvement)
boolean
FirstOther,specify
Item
First Other, specify
text
SecondOther,specify
Item
Second Other, specify
text
Item Group
Prior Systemic Therapy
PriorAdjuvantHormonalTherapyInd
Item
Prior Adjuvant Hormonal Therapy? (do not include steroids given with chemotherapy)
boolean
PriorMetastatic/RecurrentHormonalTherapyInd
Item
Prior Metastatic/Recurrent Hormonal Therapy? (do not include steroids given with chemotherapy)
boolean
PriorAdjuvantChemotherapyInd
Item
Prior Adjuvant Chemotherapy? (include pre-op chemotherapy at diagnosis)
boolean
PriorMetastatic/RecurrentChemotherapyInd
Item
Prior Chemotherapy for Metastasis or Recurrence?
boolean
PriorAdjuvantHighDoseChemotherapy/AutologousStemCellTransplant?
Item
Prior Adjuvant High Dose Chemotherapy/Autologous Stem Cell Transplant?
boolean
PriorHighDoseChemotherapy/AutologousStemCellTransplantforMetastasisorRecurrence?
Item
Prior High Dose Chemotherapy/Autologous Stem Cell Transplant for Metastasis or Recurrence?
boolean
PriorAdjuvantImmunotherapyInd
Item
Prior Adjuvant Immunotherapy?
boolean
PriorMetastatic/RecurrentImmunotherapyInd
Item
Prior Immunotherapy for Metastasis or Recurrence?
boolean
PriorAdjuvantOtherTherapyInd
Item
Prior Adjuvant Other Therapy?
boolean
PriorMetastatic/RecurrentOtherTherapyInd
Item
Prior Metastatic/Recurrent Other Therapy?
boolean
Item Group
Prior Systemic Regimens
PriorTreatmentRegimenName(s)
Item
Prior Treatment Regimen Name(s)
text
PriorTreatmentRegimenBeginDate
Item
Prior Treatment Regimen Start Date (M/D/Y)
date
PriorTreatmentRegimenEndDate
Item
Prior Treatment Regimen End Date (M/D/Y)
date
Item
Prior Treatment Regimen Type
text
CL.34
Code List
Prior Treatment Regimen Type
CL Item
Adjuvant (adjuvant)
C25722 (NCI Thesaurus)
C1522673 (UMLS 2011AA)
CL Item
Neoadjuvant (neoadjuvant)
CL Item
Advanced (advanced)
C25411 (NCI Thesaurus)
C0205179 (UMLS 2011AA)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item Group
Comments
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
Date
Item
Date
text
Item Group
Ccrr Module For E2100 On-study Form (e2100)
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video