ID

10297

Beschrijving

ECOG Non-Protocol Therapy Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC221E8E-B0F2-153B-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC221E8E-B0F2-153B-E034-0003BA12F5E7

Trefwoorden

Versies (2)
  1. 27-08-12 27-08-12 -
  2. 23-05-15 23-05-15 -
Geüploaded op

23 mei 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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ECOG Non-Protocol Therapy Form (E2100)

Engels

NOTE: Submit ECOG Second Primary Form if applicable.

1 Formulieren  
  1. StudyEvent: ECOG Non-Protocol Therapy Form (E2100)
    1. NOTE: Submit ECOG Second Primary Form if applicable.
ECOG clinical trial administrative data
Beschrijving

ECOG clinical trial administrative data

ECOG Protocol No.
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Patient ID
Beschrijving

ECOGPatientID

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

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

Patient'sName

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Participating Group Patient ID
Beschrijving

ParticipatingGroupPatientID

Datatype

text

Institution/Affiliate
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Are data amended?
Beschrijving

AmendedDataInd

Datatype

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Non-protocol therapy assessment
Beschrijving

Non-protocol therapy assessment

Date of FIRST non-protocol therapy (if given prior to progression/relapse from protocol therapy:)
Beschrijving

Non-ProtocolTherapyDate,First

Datatype

date

Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen)
Beschrijving

Type(s)offirstnon-protocoltherapy

Datatype

text

Name of other non-protocol therapy
Beschrijving

OtherNon-ProtocolTherapyName

Datatype

text

Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
Beschrijving

Wasthenon-protocoltherapygivenforthediseaseofthisprotocol?

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

Investigator Signature
Beschrijving

InvestigatorSignature

Datatype

text

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

Date

Datatype

text

Ccrr Module For Ecog Non-protocol Therapy Form (e2100)
Beschrijving

Ccrr Module For Ecog Non-protocol Therapy Form (e2100)

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Similar models

NOTE: Submit ECOG Second Primary Form if applicable.

1 Formulieren
  1. StudyEvent: ECOG Non-Protocol Therapy Form (E2100)
    1. NOTE: Submit ECOG Second Primary Form if applicable.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
Non-protocol therapy assessment
Non-ProtocolTherapyDate,First
Item
Date of FIRST non-protocol therapy (if given prior to progression/relapse from protocol therapy:)
date
Item
Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen)
text
CL.2
Code List
Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen)
CL Item
Non-protocol Chemotherapy (Non-protocol Chemotherapy)
CL Item
Non-protocol Hormonal Therapy (Non-protocol Hormonal Therapy)
CL Item
Non-protocol Immunotherapy/biological Response Modifiers (Non-protocol Immunotherapy/Biological Response Modifiers)
CL Item
Non-protocol High Dose Chemotherapy/stem Cell Transplant (autologous Or Allogeneic) (Non-protocol High Dose Chemotherapy/Stem Cell Transplant (Autologous or Allogeneic))
CL Item
Non-protocol Surgery (Non-protocol Surgery)
CL Item
Non-protocol Radiation Therapy (Non-protocol Radiation Therapy)
CL Item
Other Non-protocol Therapy (Other Non-protocol Therapy)
OtherNon-ProtocolTherapyName
Item
Name of other non-protocol therapy
text
Item
Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.3
Code List
Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (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 Ecog Non-protocol Therapy Form (e2100)
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