ID

10300

Beschreibung

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

Stichworte

Versionen (2)
  1. 27.08.12 27.08.12 -
  2. 23.05.15 23.05.15 -
Hochgeladen am

23. Mai 2015

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

E2100 Treatment Form (E2100)

Englisch

Form No. 1578

1 Formulare  
  1. StudyEvent: E2100 Treatment Form (E2100)
    1. Form No. 1578
ECOG clinical trial administrative data
Beschreibung

ECOG clinical trial administrative data

ECOG Protocol No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Patient ID
Beschreibung

ECOGPatientID

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

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

Patient'sName

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Participating Group Patient ID
Beschreibung

ParticipatingGroupPatientID

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Are data amended?
Beschreibung

AmendedDataInd

Datentyp

boolean

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

Vital Status

Patient's Vital Status
Beschreibung

Patient'sVitalStatus

Datentyp

text

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

DeathDate/LastContactDate

Datentyp

date

Cause of Death (if applicable)
Beschreibung

Causeofdeath

Datentyp

text

Describe cause of death
Beschreibung

DeathReason,Specify

Datentyp

text

Treatment Cycle Information
Beschreibung

Treatment Cycle Information

Cycle Start Date (M D Y)
Beschreibung

CourseBeginDate

Datentyp

date

Cycle Number (Paclitaxel Dose mg)
Beschreibung

CycleNumber

Datentyp

text

Dose 1 (Paclitaxel)
Beschreibung

Dose1(Paclitaxel)

Datentyp

float

Dose 2 (Paclitaxel)
Beschreibung

Dose2(Paclitaxel)

Datentyp

float

Dose 3 (Paclitaxel) (If applicable)
Beschreibung

Dose3(Paclitaxel)

Datentyp

float

Dose 1 (Bevacizumab)
Beschreibung

Dose1(Bevacizumab)

Datentyp

float

Dose 2 (Bevacizumab)
Beschreibung

Dose2(Bevacizumab)

Datentyp

float

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

Werethereanydosemodificationsoradditions/omissionstoprotocoltreatmentthisreportperiod?

Datentyp

text

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

Wasanynon-protocoltherapygivenduringprotocoltreatment(notpreviouslyreported)?

Datentyp

boolean

End of treatment evaluation
Beschreibung

End of treatment evaluation

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

ProtocolTreatmentAdministeredEndDate

Datentyp

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:)
Beschreibung

Reasontreatmentended

Datentyp

text

specify Complicating Disease
Beschreibung

specifyComplicatingDisease

Datentyp

text

specify Other Reasons (reason treatment ended)
Beschreibung

specifyOtherReasons(reasontreatmentended)

Datentyp

text

Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

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

Date

Datentyp

text

Ccrr Module For E2100 Treatment Form (e2100)
Beschreibung

Ccrr Module For E2100 Treatment Form (e2100)

Zum Seitenanfang zurückkehren

Ähnliche Modelle

Form No. 1578

1 Formulare
  1. StudyEvent: E2100 Treatment Form (E2100)
    1. Form No. 1578
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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
CL.2
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
CL.3
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
CL.4
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
CL.6
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)
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video