ID

10324

Descripción

S0100 OFF TREATMENT NOTICE Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB544B0-C752-4414-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB544B0-C752-4414-E034-0003BA12F5E7

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 -
  2. 28/5/15 28/5/15 -
Subido en

28 de mayo de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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S0100 OFF TREATMENT NOTICE

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: S0100 OFF TREATMENT NOTICE
    1. No Instruction available.
SWOG clinical trial administrative data
Descripción

SWOG clinical trial administrative data

SWOG Patient ID
Descripción

SWOGPatientID

Tipo de datos

text

SWOG Study No.
Descripción

SWOGStudyNo.

Tipo de datos

text

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Patient Initials (L, F M)
Descripción

PatientInitials

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Physician (Groups other than SWOG)
Descripción

TreatingPhysician

Tipo de datos

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Group Name
Descripción

GroupName

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study No.
Descripción

StudyNo.

Tipo de datos

text

Pt. ID
Descripción

Pt.ID

Tipo de datos

text

Treatment information
Descripción

Treatment information

Treatment Start Date
Descripción

TreatmentStartDate

Tipo de datos

date

Treatment End Date
Descripción

TreatmentEndDate

Tipo de datos

date

Regimen or Procedure or Site(s) (If more room is needed, please continue on a separate page.)
Descripción

RegimenorProcedureorSite(s)

Tipo de datos

text

Off Treatment Reason (select one)
Descripción

OffTreatmentReason

Tipo de datos

text

Patient refused, due to toxicity, specify
Descripción

OffTreatmentReason,Toxicity

Tipo de datos

text

Patient refused, due to toxicity, specify
Descripción

OffTreatmentReason,Toxicity

Tipo de datos

text

Sites (progression or relapse)
Descripción

Progressionorrelapse,specifysite

Tipo de datos

text

Other, specify (Off Treatment Date)
Descripción

OffTreatmentReason,Other

Tipo de datos

text

Other, specify (Off Treatment Date)
Descripción

OffTreatmentReason,Other

Tipo de datos

text

Date of completion, progression, death or decision to discontinue therapy
Descripción

Dateofcompletion,progression,deathordecisiontodiscontinuetherapy

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Will patient receive further treatment?
Descripción

FurtherTreatmentInd

Tipo de datos

text

Yes, specify (further treatment)
Descripción

FurtherTreatmentSpecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C25519
UMLS 2011AA ObjectClass
C1517331
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Date of Last Contact (or death)
Descripción

DeathDate/LastContactDate

Tipo de datos

date

Vital Status
Descripción

Patient'sVitalStatus

Tipo de datos

text

Comments
Descripción

Comments

Comments
Descripción

Comments

Tipo de datos

text

Ccrr Module For S0100 Off Treatment Notice
Descripción

Ccrr Module For S0100 Off Treatment Notice

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: S0100 OFF TREATMENT NOTICE
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
SWOG clinical trial administrative data
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F M)
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician (Groups other than SWOG)
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID
text
Item Group
Treatment information
TreatmentStartDate
Item
Treatment Start Date
date
TreatmentEndDate
Item
Treatment End Date
date
RegimenorProcedureorSite(s)
Item
Regimen or Procedure or Site(s) (If more room is needed, please continue on a separate page.)
text
Item
Off Treatment Reason (select one)
text
CL.1
Code List
Off Treatment Reason (select one)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Medically required, due to toxicity, specify (Medically required, due to toxicity, specify)
CL Item
Patient refused, due to toxicity, specify (Patient refused, due to toxicity, specify)
CL Item
Patient refused, other than toxicity, specify (Patient refused, other than toxicity, specify)
CL Item
Progression or relapse (Progression or relapse)
CL Item
Death (Death)
CL Item
Other, Specify (Other, specify)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Death Of Patient Occurred After The Patient Began Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death On Study (Death on study)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Progression Of Disease Occurred Prior To The Patient Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Toxicity/side Effects/complications (Toxicity/Side effects/Complications)
OffTreatmentReason,Toxicity
Item
Patient refused, due to toxicity, specify
text
OffTreatmentReason,Toxicity
Item
Patient refused, due to toxicity, specify
text
Progressionorrelapse,specifysite
Item
Sites (progression or relapse)
text
OffTreatmentReason,Other
Item
Other, specify (Off Treatment Date)
text
OffTreatmentReason,Other
Item
Other, specify (Off Treatment Date)
text
Dateofcompletion,progression,deathordecisiontodiscontinuetherapy
Item
Date of completion, progression, death or decision to discontinue therapy
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Will patient receive further treatment?
text
CL.2
Code List
Will patient receive further treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
FurtherTreatmentSpecify
Item
Yes, specify (further treatment)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25519 (NCI Thesaurus ObjectClass)
C1517331 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
DeathDate/LastContactDate
Item
Date of Last Contact (or death)
date
Item
Vital Status
text
CL.3
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0100 Off Treatment Notice
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