ID

10286

Description

E2100 Toxicity Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC352024-CFAE-2651-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC352024-CFAE-2651-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 5/23/15 5/23/15 -
Uploaded on

May 23, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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E2100 Toxicity Form (E2100)

English

Form No. 1579

1 forms  
  1. StudyEvent: E2100 Toxicity Form (E2100)
    1. Form No. 1579
ECOG Clinical trial administrative data
Description

ECOG Clinical trial administrative data

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient ID
Description

ECOGPatientID

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C16154
UMLS 2011AA ValueDomain-2
C1704379
Adverse Event Reporting From Date (M D Y)
Description

CTCAdverseEventReportBeginDate

Data type

date

Adverse Event Reporting To Date (M D Y)
Description

CTCAdverseEventReportEndDate

Data type

date

Patient's Name
Description

Patient'sName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Are data amended? (CTC Adverse Event - Hematologic)
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Adverse event assessment
Description

Adverse event assessment

CTC Code
Description

CTC Code

Data type

text

CTC Adverse Event Term
Description

CTCAdverseEventTerm

Data type

text

CTC Adverse Event Grade (this period)
Description

CTCAdverseEventGrade

Data type

text

CTC ADVERSE Event Attribution Code
Description

CTCAdverseEventAttributionCode

Data type

text

Other CTC Adverse Event Term(s) not listed (Use CTC terminology)
Description

CTCAdverseEventTerm,Other

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Investigator Signature
Description

InvestigatorSignature

Data type

text

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

Date

Data type

text

Ccrr Module For E2100 Toxicity Form (e2100)
Description

Ccrr Module For E2100 Toxicity Form (e2100)

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Similar models

Form No. 1579

1 forms
  1. StudyEvent: E2100 Toxicity Form (E2100)
    1. Form No. 1579
Name
Type
Description | Question | Decode (Coded Value)
Data type
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)
CTCAdverseEventReportBeginDate
Item
Adverse Event Reporting From Date (M D Y)
date
CTCAdverseEventReportEndDate
Item
Adverse Event Reporting To Date (M D Y)
date
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? (CTC Adverse Event - Hematologic)
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Adverse event assessment
Item
CTC Code
text
CL.6
Code List
CTC Code
CL Item
Al01 (AL01)
CL Item
Pa02 (PA02)
CL Item
He04 (HE04)
CL Item
In02 (IN02)
CL Item
Cn02 (CN02)
CL Item
He01 (HE01)
CL Item
He02 (HE02)
CL Item
Cg07 (CG07)
CL Item
Cg08 (CG08)
CL Item
In03 (IN03)
CL Item
In03 (IN03)
CL Item
In05 (IN05)
CL Item
Mu02 (MU02)
CL Item
Pa10 (PA10)
CL Item
Ne20 (NE20)
CL Item
Re08 (RE08)
CL Item
Hp08 (HP08)
CL Item
Gi27 (GI27)
CL Item
Cg14 (CG14)
Item
CTC Adverse Event Term
text
CL.7
Code List
CTC Adverse Event Term
CL Item
Allergic Reaction (Allergic reaction)
C0085600 (NCI Metathesaurus)
CL Item
Arthralgia (Arthralgia)
C0003862 (NCI Metathesaurus)
CL Item
Epistaxis (Epistaxis)
C26766 (NCI Thesaurus)
C0014591 (UMLS 2011AA)
CL Item
Febrile Neutropenia W/o Infection (Febrile neutropenia w/o infection)
CL Item
Fever W/o Gr 3/4 Neutropenia (Fever w/o Gr 3/4 neutropenia)
CL Item
Hemorrhage W/ Grade 3 Or 4 Platelets (Hemorrhage w/ grade 3 or 4 platelets)
CL Item
Hemorrhage W/o Grade 3 Or 4 Platelets (Hemorrhage w/o grade 3 or 4 platelets)
CL Item
Hypertension (Hypertension)
C3117 (NCI Thesaurus)
C0020538 (UMLS 2011AA)
CL Item
Hypotension (Hypotension)
C3128 (NCI Thesaurus)
C0020649 (UMLS 2011AA)
CL Item
Infection W/grade 3 Or 4 Neutropenia (Infection w/grade 3 or 4 neutropenia)
CL Item
Infection W/ Unknown Anc (Infection w/ unknown ANC)
CL Item
Infection W/o Neutropenia (Infection w/o neutropenia)
CL Item
Muscle Weakness (Muscle weakness)
CL Item
Myalgia (Myalgia)
C27009 (NCI Thesaurus)
C0231528 (UMLS 2011AA)
CL Item
Neuropathy-sensory (Neuropathy-sensory)
CL Item
Proteinuria (Proteinuria)
C38012 (NCI Thesaurus)
C0033687 (UMLS 2011AA)
CL Item
Sgot (ast) (SGOT (AST))
C25202 (NCI Thesaurus)
C0242192 (UMLS 2011AA)
CL Item
Stomatitis (Stomatitis)
C26887 (NCI Thesaurus)
C0038362 (UMLS 2011AA)
CL Item
Thrombosis/embolism (including Dvt And Pe) (Thrombosis/embolism (including DVT and PE))
Item
CTC Adverse Event Grade (this period)
text
CL.10
Code List
CTC Adverse Event Grade (this period)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
CTC ADVERSE Event Attribution Code
text
CL.11
Code List
CTC ADVERSE Event Attribution Code
CL Item
Unrelated (unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (unlikely)
CL Item
Possible (possible)
C0332149 (NCI Metathesaurus)
CL Item
Probable (probable)
C0332148 (NCI Metathesaurus)
CTCAdverseEventTerm,Other
Item
Other CTC Adverse Event Term(s) not listed (Use CTC terminology)
text
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 Toxicity Form (e2100)
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