ID

10484

Description

CALGB: 80101 TREATMENT FORM Chemotherapy and Radiation Therapy After Surgery in Treating Patients With Stomach or Esophageal Cancer NCT00052910 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA6CD3D-F968-5976-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA6CD3D-F968-5976-E034-080020C9C0E0

Keywords

Versions (3)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 6/2/15 6/2/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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CALGB: 80101 TREATMENT FORM NCT00052910

English

No Instruction available.

1 forms  
  1. StudyEvent: CALGB: 80101 TREATMENT FORM
    1. No Instruction available.
CALGB clinical trial administrative data
Description

CALGB clinical trial administrative data

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBProtocolNumber

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Amended data?
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient's Name
Description

PatientName,Last

Data type

text

Participating Group
Description

ParticipatingGroupCode

Data type

text

Patient Hospital Number
Description

PatientMedicalRecordNumber

Data type

text

Participating Group Protocol No.
Description

Particip.GroupProtocolNumber

Data type

float

Main Member Institution/Adjunct
Description

InstitutionName

Data type

text

Participating Group Patient No.
Description

PatientStudyID,ParticipatingGroup

Data type

text

Treatment Summary
Description

Treatment Summary

Cycle Number
Description

CourseIdentification

Data type

text

Start date of first treatment
Description

FirstTreatmentStartDate

Data type

date

Date of last treatment
Description

LastTreatmentDate

Data type

date

Were there any dose modifications or additions/omissions to protocol treatment?
Description

DoseModification(Change)

Data type

text

Reason for therapy modification
Description

TherapyModificationReason

Data type

text

Were there any unscheduled interruptions in radiation therapy?
Description

RTInterruptionsInd

Data type

text

RT interruptions reason
Description

RTInterruptionsReason

Data type

text

Reason treatment ended
Description

OffTreatmentReason

Data type

text

Other, specify
Description

CytogeneticAnalysis,OtherReason,NoSuccess

Data type

text

Completed by
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date completed
Description

FormCompletionDate,Original

Data type

date

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: CALGB: 80101 TREATMENT FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB clinical trial administrative data
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
AmendedDataInd
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
PatientName,Last
Item
Patient's Name
text
ParticipatingGroupCode
Item
Participating Group
text
PatientMedicalRecordNumber
Item
Patient Hospital Number
text
Particip.GroupProtocolNumber
Item
Participating Group Protocol No.
float
InstitutionName
Item
Main Member Institution/Adjunct
text
PatientStudyID,ParticipatingGroup
Item
Participating Group Patient No.
text
Item Group
Treatment Summary
CourseIdentification
Item
Cycle Number
text
FirstTreatmentStartDate
Item
Start date of first treatment
date
LastTreatmentDate
Item
Date of last treatment
date
Item
Were there any dose modifications or additions/omissions to protocol treatment?
text
CL.1
Code List
Were there any dose modifications or additions/omissions to protocol treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, planned per protocol (Yes, planned per protocol)
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
Item
Reason for therapy modification
text
CL.2
Code List
Reason for therapy modification
CL Item
Adverse Event Or Toxicity (Adverse event or toxicity (including death))
CL Item
Parient Refusal/noncompliance (Patient refusal/noncompliance)
CL Item
Scheduling (Scheduling (e.g., physician schedule, patient schedule, holiday, vacation, etc.))
CL Item
Dosing Error (Dosing error)
Item
Were there any unscheduled interruptions in radiation therapy?
text
CL.3
Code List
Were there any unscheduled interruptions in radiation therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, planned per protocol (Yes, planned per protocol)
CL Item
Yes, unplanned (Yes, unplanned)
Item
RT interruptions reason
text
CL.4
Code List
RT interruptions reason
CL Item
Adverse event or toxicity (including death) (Adverse event or toxicity (including death))
CL Item
Patient refusal/noncompliance (Patient refusal/noncompliance)
CL Item
Scheduling (e.g., physician schedule, patient schedule, holiday, vacation, etc.) (Scheduling (e.g., physician schedule, patient schedule, holiday, vacation, etc.))
CL Item
Dosing error (Dosing error)
Item
Reason treatment ended
text
CL.5
Code List
Reason treatment ended
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 on study (Death on study)
CL Item
Patient withdrawal or refusal after beginning protocol treatment (Patient withdrawal or refusal after beginning protocol treatment)
CL Item
Patient withdrawal or refusal prior to beginning protocol treatment (Patient withdrawal or refusal prior to beginning protocol treatment)
CL Item
Alternative therapy (Alternative therapy)
CL Item
Patient off-treatment for other complicating disease (Patient off-treatment for other complicating disease)
CL Item
Disease progression, relapse prior to beginning protocol therapy (Disease progression, relapse prior to beginning protocol therapy)
CL Item
Death prior to beginning protocol therapy (Death prior to beginning protocol therapy)
CL Item
Other, specify (Other, specify)
CytogeneticAnalysis,OtherReason,NoSuccess
Item
Other, specify
text
PersonCompletingForm,FirstName
Item
Completed by
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date completed
date
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