ID

10285

Descrição

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

Palavras-chave

Versões (2)
  1. 27/08/2012 27/08/2012 -
  2. 23/05/2015 23/05/2015 -
Transferido a

23 de maio de 2015

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy
Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo
Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

E2100 On-Study Form (E2100)

Inglês

Form No. 1575

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

ECOG Clinical trial administrative data

ECOG Protocol No.
Descrição

ECOGProtocolNo.

Tipo de dados

text

ECOG Patient ID
Descrição

ECOGPatientID

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

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

Patient'sName

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Participating Group Patient ID
Descrição

ParticipatingGroupPatientID

Tipo de dados

text

Institution/Affiliate
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

Are data amended?
Descrição

AmendedDataInd

Tipo de dados

boolean

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

Patient Characteristics

Menopausal Status (Choose one:)
Descrição

MenopausalStatus

Tipo de dados

text

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

Advanced Disease Description

ER Status (most recent)
Descrição

ERStatus

Tipo de dados

text

Receptor Status Timing (most recent)
Descrição

ReceptorStatusTiming

Tipo de dados

text

ER Timing, Other, Specify
Descrição

ERTiming,Other

Tipo de dados

text

PgR Status (most recent)
Descrição

PgRStatus

Tipo de dados

text

PgR Timing, Other, Specify
Descrição

PgRTiming,Other

Tipo de dados

text

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

Her2/Neuexpressionstatusbyimmunohistochemistry

Tipo de dados

text

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

Her2/NeuexpressionstatusbyFISH

Tipo de dados

text

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

FirstPositiveBiopsyDate

Tipo de dados

date

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

DateRecurrent,Progressive,orMetastaticDiseaseFirstDiagnosed

Tipo de dados

date

Site(s) Of Involvement
Descrição

Site(s) Of Involvement

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

Local-regional(sitesofinvolvement)

Tipo de dados

text

Ipsilateral supraclavicular nodes (sites of involvement)
Descrição

Ipsilateralsupraclavicularnodes(sitesofinvolvement)

Tipo de dados

boolean

Opposite breast (sites of involvement)
Descrição

Oppositebreast(sitesofinvolvement)

Tipo de dados

boolean

Distant nodes (sites of involvement)
Descrição

Distantnodes(sitesofinvolvement)

Tipo de dados

boolean

Distant skin/subcutaneous tissue (sites of involvement)
Descrição

Distantskin/subcutaneoustissue(sitesofinvolvement)

Tipo de dados

boolean

Bone (sites of involvement)
Descrição

Bone(sitesofinvolvement)

Tipo de dados

boolean

Bone marrow (sites of involvement)
Descrição

Bonemarrow(sitesofinvolvement)

Tipo de dados

boolean

Lung (sites of involvement)
Descrição

Lung(sitesofinvolvement)

Tipo de dados

boolean

Liver (sites of involvement)
Descrição

Liver(sitesofinvolvement)

Tipo de dados

boolean

Pleura (sites of involvement)
Descrição

Pleura(sitesofinvolvement)

Tipo de dados

boolean

Brain (sites of involvement)
Descrição

Brain(sitesofinvolvement)

Tipo de dados

boolean

Other CNS (sites of involvement)
Descrição

OtherCNS(sitesofinvolvement)

Tipo de dados

boolean

First Other, specify (sites of involvement)
Descrição

FirstOther,specify(sitesofinvolvement)

Tipo de dados

boolean

Second Other, specify (sites of involvement)
Descrição

SecondOther,specify(sitesofinvolvement)

Tipo de dados

boolean

First Other, specify
Descrição

FirstOther,specify

Tipo de dados

text

Second Other, specify
Descrição

SecondOther,specify

Tipo de dados

text

Prior Systemic Therapy
Descrição

Prior Systemic Therapy

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

PriorAdjuvantHormonalTherapyInd

Tipo de dados

boolean

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

PriorMetastatic/RecurrentHormonalTherapyInd

Tipo de dados

boolean

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

PriorAdjuvantChemotherapyInd

Tipo de dados

boolean

Prior Chemotherapy for Metastasis or Recurrence?
Descrição

PriorMetastatic/RecurrentChemotherapyInd

Tipo de dados

boolean

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

PriorAdjuvantHighDoseChemotherapy/AutologousStemCellTransplant?

Tipo de dados

boolean

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

PriorHighDoseChemotherapy/AutologousStemCellTransplantforMetastasisorRecurrence?

Tipo de dados

boolean

Prior Adjuvant Immunotherapy?
Descrição

PriorAdjuvantImmunotherapyInd

Tipo de dados

boolean

Prior Immunotherapy for Metastasis or Recurrence?
Descrição

PriorMetastatic/RecurrentImmunotherapyInd

Tipo de dados

boolean

Prior Adjuvant Other Therapy?
Descrição

PriorAdjuvantOtherTherapyInd

Tipo de dados

boolean

Prior Metastatic/Recurrent Other Therapy?
Descrição

PriorMetastatic/RecurrentOtherTherapyInd

Tipo de dados

boolean

Prior Systemic Regimens
Descrição

Prior Systemic Regimens

Prior Treatment Regimen Name(s)
Descrição

PriorTreatmentRegimenName(s)

Tipo de dados

text

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

PriorTreatmentRegimenBeginDate

Tipo de dados

date

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

PriorTreatmentRegimenEndDate

Tipo de dados

date

Prior Treatment Regimen Type
Descrição

PriorTreatmentRegimenType

Tipo de dados

text

Comments
Descrição

Comments

Comments
Descrição

Comments

Tipo de dados

text

Investigator Signature
Descrição

InvestigatorSignature

Tipo de dados

text

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

Date

Tipo de dados

text

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

Ccrr Module For E2100 On-study Form (e2100)

Voltar ao início da página

Similar models

Form No. 1575

1 Formulários
  1. StudyEvent: E2100 On-Study Form (E2100)
    1. Form No. 1575
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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)
Voltar ao início da página 

Contacto

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

Ajuda

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial