ID

1047

Beschreibung

Bilateral Hormone Receptor Form (Form 24-BF) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=01609FC5-4143-11A6-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=01609FC5-4143-11A6-E044-0003BA3F9857

Stichworte

Versionen (2)
  1. 26.08.12 26.08.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

26. August 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Pathology - Bilateral Hormone Receptor Form (Form 24-BF) - 2409866v1.0

Englisch

HORMONE RECEPTOR FORM (Form 24-F) Instructions: This form is to be completed and submitted after hormone receptor analysis is performed, within one done at first recurrence. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done.

1 Formulare  
Ccrr Module For Hormone Receptor Form (form 24-f)
Beschreibung

Ccrr Module For Hormone Receptor Form (form 24-f)

Patient ID No. (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Beschreibung

PatientStudyID,CoordinatingGroup

Datentyp

text

Patient Initials (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Beschreibung

PatientInitialsName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Patient's Date of Birth (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Beschreibung

PatientBirthDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Participating Center/Affiliate
Beschreibung

ParticipatingCenter/Affiliate

Datentyp

text

Center Code
Beschreibung

ParticipatingGroupCode

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
This form is being completed for
Beschreibung

BreastSideAssessmentSite

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus Property
C25306
UMLS 2011AA Property
C0441987
Specimen ID Number (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Beschreibung

SpecimenID

Datentyp

double

Date Specimen Collected (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Beschreibung

SpecimenCollectionDate

Datentyp

date

ER % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
Beschreibung

EstrogenReceptorPositivePercentage

Datentyp

double

Maßeinheiten
  • %
Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
%
PR % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
Beschreibung

ProgesteroneReceptorPositivePercentage

Datentyp

double

Maßeinheiten
  • %
Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C17075
UMLS 2011AA ObjectClass
C0034833
NCI Thesaurus Property
C25554
UMLS 2011AA Property
C0441889
%
ER status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Beschreibung

ERStatus

Datentyp

text

PgR status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Beschreibung

PgRStatus

Datentyp

text

Investigator Signature
Beschreibung

InvestigatorSignatureText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beschreibung

InvestigatorSignatureDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Zum Seitenanfang zurückkehren

Ähnliche Modelle

HORMONE RECEPTOR FORM (Form 24-F) Instructions: This form is to be completed and submitted after hormone receptor analysis is performed, within one done at first recurrence. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done.

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Ccrr Module For Hormone Receptor Form (form 24-f)
PatientStudyID,CoordinatingGroup
Item
Patient ID No. (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
PatientInitialsName
Item
Patient Initials (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientBirthDate
Item
Patient's Date of Birth (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Item
This form is being completed for
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25306 (NCI Thesaurus Property)
C0441987 (UMLS 2011AA Property)
CL.1
Code List
This form is being completed for
CL Item
Left Breast/side (Left breast/side)
CL Item
Right Breast/side (Right breast/side)
SpecimenID
Item
Specimen ID Number (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
double
SpecimenCollectionDate
Item
Date Specimen Collected (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
date
EstrogenReceptorPositivePercentage
Item
ER % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
ProgesteroneReceptorPositivePercentage
Item
PR % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C0034833 (UMLS 2011AA ObjectClass)
C25554 (NCI Thesaurus Property)
C0441889 (UMLS 2011AA Property)
Item
ER status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
CL.2
Code List
ER status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
PgR status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
CL.3
Code List
PgR status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
InvestigatorSignatureText
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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