ID

10300

Description

E2100 Treatment Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC347692-7E8B-258D-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC347692-7E8B-258D-E034-0003BA12F5E7

Keywords

  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 Treatment Form (E2100)

Form No. 1578

  1. StudyEvent: E2100 Treatment Form (E2100)
    1. Form No. 1578
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
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?
Description

AmendedDataInd

Data type

boolean

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

Vital Status

Patient's Vital Status
Description

Patient'sVitalStatus

Data type

text

Date of Last Contact or Death (M D Y)
Description

DeathDate/LastContactDate

Data type

date

Cause of Death (if applicable)
Description

Causeofdeath

Data type

text

Describe cause of death
Description

DeathReason,Specify

Data type

text

Treatment Cycle Information
Description

Treatment Cycle Information

Cycle Start Date (M D Y)
Description

CourseBeginDate

Data type

date

Cycle Number (Paclitaxel Dose mg)
Description

CycleNumber

Data type

text

Dose 1 (Paclitaxel)
Description

Dose1(Paclitaxel)

Data type

float

Dose 2 (Paclitaxel)
Description

Dose2(Paclitaxel)

Data type

float

Dose 3 (Paclitaxel) (If applicable)
Description

Dose3(Paclitaxel)

Data type

float

Dose 1 (Bevacizumab)
Description

Dose1(Bevacizumab)

Data type

float

Dose 2 (Bevacizumab)
Description

Dose2(Bevacizumab)

Data type

float

Were there any dose modifications or additions/omissions to protocol treatment this report period ? (Choose one:)
Description

Werethereanydosemodificationsoradditions/omissionstoprotocoltreatmentthisreportperiod?

Data type

text

Was any non-protocol therapy given during protocol treatment (not previously reported)?
Description

Wasanynon-protocoltherapygivenduringprotocoltreatment(notpreviouslyreported)?

Data type

boolean

End of treatment evaluation
Description

End of treatment evaluation

Last date protocol therapy was given (M D Y)
Description

ProtocolTreatmentAdministeredEndDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Reason treatment ended (Choose one:)
Description

Reasontreatmentended

Data type

text

specify Complicating Disease
Description

specifyComplicatingDisease

Data type

text

specify Other Reasons (reason treatment ended)
Description

specifyOtherReasons(reasontreatmentended)

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 Treatment Form (e2100)
Description

Ccrr Module For E2100 Treatment Form (e2100)

Similar models

Form No. 1578

  1. StudyEvent: E2100 Treatment Form (E2100)
    1. Form No. 1578
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)
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
Vital Status
Item
Patient's Vital Status
text
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of Last Contact or Death (M D Y)
date
Item
Cause of Death (if applicable)
text
Code List
Cause of Death (if applicable)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Other Cause (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Describe cause of death
text
Item Group
Treatment Cycle Information
CourseBeginDate
Item
Cycle Start Date (M D Y)
date
CycleNumber
Item
Cycle Number (Paclitaxel Dose mg)
text
Dose1(Paclitaxel)
Item
Dose 1 (Paclitaxel)
float
Dose2(Paclitaxel)
Item
Dose 2 (Paclitaxel)
float
Dose3(Paclitaxel)
Item
Dose 3 (Paclitaxel) (If applicable)
float
Dose1(Bevacizumab)
Item
Dose 1 (Bevacizumab)
float
Dose2(Bevacizumab)
Item
Dose 2 (Bevacizumab)
float
Item
Were there any dose modifications or additions/omissions to protocol treatment this report period ? (Choose one:)
text
Code List
Were there any dose modifications or additions/omissions to protocol treatment this report period ? (Choose one:)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Planned (Yes, planned)
CL Item
Yes, Unplanned (Yes, unplanned)
Wasanynon-protocoltherapygivenduringprotocoltreatment(notpreviouslyreported)?
Item
Was any non-protocol therapy given during protocol treatment (not previously reported)?
boolean
Item Group
End of treatment evaluation
ProtocolTreatmentAdministeredEndDate
Item
Last date protocol therapy was given (M D Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C0442711 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Reason treatment ended (Choose one:)
text
Code List
Reason treatment ended (Choose one:)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Toxicity/side Effects/complications (Toxicity/side effects/complications)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
7 (7)
CL Item
Other Complicating Disease (Other complicating disease)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
specifyComplicatingDisease
Item
specify Complicating Disease
text
specifyOtherReasons(reasontreatmentended)
Item
specify Other Reasons (reason treatment ended)
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 Treatment Form (e2100)

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