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10294

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ECOG Nontarget Lesions Supplemental Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC328486-403E-246F-E034-0003BA12F5E7

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC328486-403E-246F-E034-0003BA12F5E7

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Versions (3)
  1. 27/08/2012 27/08/2012 -
  2. 23/05/2015 23/05/2015 -
  3. 28/07/2015 28/07/2015 - Julian Varghese
Téléchargé le

23 mai 2015

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Creative Commons BY-NC 3.0 Legacy
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    ECOG Nontarget Lesions Supplemental Form (E2100)

    Anglais

    Form No. 1565

    1 Formulaires  
    1. StudyEvent: ECOG Nontarget Lesions Supplemental Form (E2100)
      1. Form No. 1565
    ECOG clinical trial administrative data
    Description

    ECOG clinical trial administrative data

    ECOG Protocol No.
    Description

    ECOGProtocolNo.

    Type de données

    text

    ECOG Patient ID
    Description

    ECOGPatientID

    Type de données

    text

    Registration Step
    Description

    RegistrationStep

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ValueDomain-2
    C16154
    UMLS 2011AA ValueDomain-2
    C1704379
    Cycle Number (Use '00' for baseline; leave blank if off-treatment or N/A)
    Description

    CycleNumber

    Type de données

    text

    Patient's Name
    Description

    Patient'sName

    Type de données

    text

    Participating Group Protocol No.
    Description

    ParticipatingGroupProtocolNo.

    Type de données

    text

    Participating Group Patient ID
    Description

    ParticipatingGroupPatientID

    Type de données

    text

    Institution/Affiliate
    Description

    MainMemberInstitution/Affiliate

    Type de données

    text

    Are data amended?
    Description

    AmendedDataInd

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Unnamed2
    Description

    Unnamed2

    Nontarget Lesions
    Description

    Nontarget Lesions

    Lesion Number
    Description

    LesionNumber

    Type de données

    float

    Site of Lesion (Multiple nontarget lesions within an organ may be combined as a single site, but must be reported in same manner as at baseline.)
    Description

    Lesion,AnatomicSite

    Type de données

    text

    Site Code (Site codes)
    Description

    LesionMeasurableEvaluationAnatomicSite

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    NCI Thesaurus ObjectClass
    C3824
    UMLS 2011AA ObjectClass
    C0221198
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus Property-2
    C37894
    UMLS 2011AA Property-2
    C1513040
    Method of Evaluation (Method of Evaluation codes)
    Description

    MethodofEvaluation

    Type de données

    text

    Date of Evaluation (M D Y)
    Description

    AssessmentDate

    Type de données

    date

    Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
    Description

    Follow-UpStatusofLesions

    Type de données

    text

    Unequivocal progressive disease in nontarget lesions is based on: (please describe) (For Site Code 04 effusion/ascites ONLY:)
    Description

    ProgressiveDiseaseNon-TargetLesionDescriptionText

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C35571
    UMLS 2011AA ObjectClass
    C1335499
    NCI Thesaurus Property
    C3824
    UMLS 2011AA Property
    C0221198
    NCI Thesaurus Property-2
    C25592
    UMLS 2011AA Property-2
    C1518389
    NCI Thesaurus Property-3
    C25365
    UMLS 2011AA Property-3
    C0678257
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    Cytology Result
    Description

    CytologyResult

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C16491
    UMLS 2011AA ObjectClass
    C0010819
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    Comments
    Description

    Comments

    Comments
    Description

    Comments

    Type de données

    text

    Investigator Signature
    Description

    InvestigatorSignature

    Type de données

    text

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

    Date

    Type de données

    text

    Ccrr Module For Ecog Nontarget Lesions Supplemental Form (e2100)
    Description

    Ccrr Module For Ecog Nontarget Lesions Supplemental Form (e2100)

    Retour au début de la page

    Similar models

    Form No. 1565

    1 Formulaires
    1. StudyEvent: ECOG Nontarget Lesions Supplemental Form (E2100)
      1. Form No. 1565
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    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)
    CycleNumber
    Item
    Cycle Number (Use '00' for baseline; leave blank if off-treatment or N/A)
    text
    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
    Unnamed2
    Item Group
    Nontarget Lesions
    LesionNumber
    Item
    Lesion Number
    float
    Lesion,AnatomicSite
    Item
    Site of Lesion (Multiple nontarget lesions within an organ may be combined as a single site, but must be reported in same manner as at baseline.)
    text
    Item
    Site Code (Site codes)
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C3824 (NCI Thesaurus ObjectClass)
    C0221198 (UMLS 2011AA ObjectClass)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C37894 (NCI Thesaurus Property-2)
    C1513040 (UMLS 2011AA Property-2)
    CL.3
    Code List
    Site Code (Site codes)
    CL Item
    Bone (Bone)
    C12366 (NCI Thesaurus)
    C0262950 (UMLS 2011AA)
    CL Item
    Brain (Brain)
    C12439 (NCI Thesaurus)
    C0006104 (UMLS 2011AA)
    CL Item
    Breast (Breast)
    C12971 (NCI Thesaurus)
    C0006141 (UMLS 2011AA)
    CL Item
    Effusion/ascites (Effusion/Ascites)
    CL Item
    Gi (GI)
    CL Item
    Gu (GU)
    CL Item
    Head & Neck (Head & Neck)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Lung (Lung)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    CL Item
    Nodes (Nodes)
    CL Item
    Skin (Skin)
    C12470 (NCI Thesaurus)
    C1123023 (UMLS 2011AA)
    CL Item
    Other (specify Site) (Other (specify site))
    Item
    Method of Evaluation (Method of Evaluation codes)
    text
    CL.4
    Code List
    Method of Evaluation (Method of Evaluation codes)
    CL Item
    Clinical Exam (Clinical Exam)
    CL Item
    Chest X-ray (Chest X-Ray)
    CL Item
    Ct Scan (CT Scan)
    CL Item
    Spiral Ct (Spiral CT)
    C20645 (NCI Thesaurus)
    C0860888 (UMLS 2011AA)
    CL Item
    Mri (MRI)
    CL Item
    Ultrasound (Ultrasound)
    C64384 (NCI Thesaurus)
    C1456803 (UMLS 2011AA)
    CL Item
    Bone Scan (Bone Scan)
    C17646 (NCI Thesaurus)
    C0203668 (UMLS 2011AA)
    CL Item
    Not Evaluated (Not evaluated)
    CL Item
    Other (specify In Comments) (Other (specify in Comments))
    AssessmentDate
    Item
    Date of Evaluation (M D Y)
    date
    Item
    Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
    text
    CL.5
    Code List
    Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
    CL Item
    Cr (CR)
    CL Item
    Incompl. Resp./sd (Incompl. resp./SD)
    CL Item
    Pd (PD)
    ProgressiveDiseaseNon-TargetLesionDescriptionText
    Item
    Unequivocal progressive disease in nontarget lesions is based on: (please describe) (For Site Code 04 effusion/ascites ONLY:)
    text
    C35571 (NCI Thesaurus ObjectClass)
    C1335499 (UMLS 2011AA ObjectClass)
    C3824 (NCI Thesaurus Property)
    C0221198 (UMLS 2011AA Property)
    C25592 (NCI Thesaurus Property-2)
    C1518389 (UMLS 2011AA Property-2)
    C25365 (NCI Thesaurus Property-3)
    C0678257 (UMLS 2011AA Property-3)
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    Item
    Cytology Result
    text
    C16491 (NCI Thesaurus ObjectClass)
    C0010819 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    CL.6
    Code List
    Cytology Result
    CL Item
    Negative (Negative)
    C25247 (NCI Thesaurus)
    C0205160 (UMLS 2011AA)
    CL Item
    Positive (Positive)
    C25246 (NCI Thesaurus)
    C1446409 (UMLS 2011AA)
    CL Item
    Not Done (Not done)
    CL281691 (NCI Metathesaurus)
    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 Ecog Nontarget Lesions Supplemental Form (e2100)
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