ID

10565

Beschrijving

Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT Radiation Therapy in Preventing CNS Metastases in Patients With Non-Small Cell Lung Cancer NCT00048997 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-7094-05D5-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-7094-05D5-E034-080020C9C0E0

Trefwoorden

Versies (4)
  1. 19-09-12 19-09-12 -
  2. 28-05-15 28-05-15 -
  3. 03-06-15 03-06-15 -
  4. 20-09-21 20-09-21 -
Geüploaded op

3 juni 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT NCT00048997

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT
    1. No Instruction available.
Header Module
Beschrijving

Header Module

Case #
Beschrijving

Case#

Datatype

text

Institution
Beschrijving

InstitutionName

Datatype

text

Institution #
Beschrijving

NCIInstitutionNumber

Datatype

text

Patient Name
Beschrijving

PatientName

Datatype

text

Patient ID #
Beschrijving

PatientID#

Datatype

text

Medical history
Beschrijving

Medical history

DATE OF LAST CLINICAL ASSESSMENT
Beschrijving

CancerFollow-upStatusDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
PATIENT'S VITAL STATUS
Beschrijving

Patient'sVitalStatus

Datatype

text

LAST CONTACT DATE / DEATH DATE
Beschrijving

DeathDate/LastContactDate

Datatype

date

CAUSE OF DEATH
Beschrijving

DeathReason

Datatype

text

Cause of death, other specify
Beschrijving

DeathReason,Specify

Datatype

text

PERFORMANCE STATUS (ZUBROD)
Beschrijving

PerformanceStatus

Datatype

text

HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (Complete Q6 A and B)
Beschrijving

ProgressionInd

Datatype

boolean

Sites of progression, lung
Beschrijving

Sitesofprogression,lung

Datatype

text

Sites of progression, Lymph nodes (distant)
Beschrijving

Sitesofprogression,Lymphnodes(distant)

Datatype

text

Sites of progression, pleural
Beschrijving

Sitesofprogression,pleural

Datatype

text

Sites of progression, adrenals
Beschrijving

Sitesofprogression,adrenals

Datatype

text

Sites of progression, liver
Beschrijving

Sitesofprogression,liver

Datatype

text

Sites of progression, bone
Beschrijving

Sitesofprogression,bone

Datatype

text

Sites of progression, CNS (Brain)
Beschrijving

Sitesofprogression,CNS(Brain)

Datatype

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25331
NCI Thesaurus ObjectClass
C12438
UMLS 2011AA ObjectClass
C0927232
CNS (Brain) Date
Beschrijving

ProgressionDate

Datatype

date

Sites of progression, Other Specify
Beschrijving

Sitesofprogression,OtherSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C17649
UMLS 2011AA ValueDomain-2
C0205394
Site of progression, other specify
Beschrijving

ProgressionSite,Other

Datatype

text

PROGRESSION ASSESSMENT
Beschrijving

ProgressionAssessmentMethod

Datatype

float

HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?
Beschrijving

NewPrimaryCancerInd

Datatype

text

NEW PRIMARY SITE
Beschrijving

NewPrimarySite

Datatype

text

NEW PRIMARY HISTOLOGIC TYPE
Beschrijving

NewPrimary,HistologicType

Datatype

text

DATE OF DIAGNOSIS
Beschrijving

NewPrimaryCancerDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
Beschrijving

Non-ProtocolTherapyInd

Datatype

text

Non-Protocol RT
Beschrijving

Non-ProtocolRTInd

Datatype

text

Date of first non-protocol therapy
Beschrijving

Non-ProtocolTherapyDate,First

Datatype

date

Non-Protocol Surgery
Beschrijving

Non-protocolSurgeryPerformedInd-3

Datatype

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass-2
C1518384
Non-Protocol Chemotherapy
Beschrijving

Non-ProtocolChemotherapyInd

Datatype

text

Other Non-Protocol therapy
Beschrijving

OtherNon-ProtocolTherapyInd

Datatype

text

Specify other
Beschrijving

OtherNon-ProtocolTherapyName

Datatype

text

Revised
Beschrijving

AmendedDataInd

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
IMT CODE TOXICITY CODE BASED ON CTEP TOXICITY TERM
Beschrijving

IMTCODETOXICITYCODEBASEDONCTEPTOXICITYTERM

Datatype

text

TERM
Beschrijving

CTCAdverseEventTerm

Datatype

text

GENERAL TOXICITY CATEGORY
Beschrijving

CTCAdverseEventCategory

Datatype

text

SEVERITY GRADE
Beschrijving

CTCAdverseEventGrade

Datatype

text

DATE OF 1ST OCCURRENCE OF GRADE=>3
Beschrijving

DATEOF1STOCCURRENCEOFGRADE=>3

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
ATTRIBUTION
Beschrijving

CTCAdverseEventAttributionCode

Datatype

text

DESCRIPTION
Beschrijving

DESCRIPTION

Datatype

text

HQ Use
Beschrijving

HQUse

Datatype

text

Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

Signature of Person Completing This Form
Beschrijving

SignatureofPersonCompletingThisForm

Datatype

text

Date
Beschrijving

FormCompletionDate,Original

Datatype

date

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header Module
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
NCIInstitutionNumber
Item
Institution #
text
PatientName
Item
Patient Name
text
PatientID#
Item
Patient ID #
text
Item Group
Medical history
CancerFollow-upStatusDate
Item
DATE OF LAST CLINICAL ASSESSMENT
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
PATIENT'S VITAL STATUS
text
CL.1
Code List
PATIENT'S VITAL STATUS
CL Item
Alive (Alive)
CL Item
Dead (Dead)
CL Item
Lost (Lost)
CL Item
Unknown (Unknown)
DeathDate/LastContactDate
Item
LAST CONTACT DATE / DEATH DATE
date
Item
CAUSE OF DEATH
text
CL.2
Code List
CAUSE OF DEATH
CL Item
Related to or probably related to the cancer under study (Related to or probably related to the cancer under study)
CL Item
(whether local, regional, or distant) ((whether local, regional, or distant))
CL Item
Related to or probably related to a second primary tumor (Related to or probably related to a second primary tumor)
CL Item
Related to or probably related to complications of protocol treatment (Related to or probably related to complications of protocol treatment)
CL Item
(explain in COMMENTS, requires a grade 5 toxicity code) ((explain in COMMENTS, requires a grade 5 toxicity code))
CL Item
Related to or probably related to complications of other treatment (Related to or probably related to complications of other treatment)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Cause of death, other specify
text
PerformanceStatus
Item
PERFORMANCE STATUS (ZUBROD)
text
ProgressionInd
Item
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (Complete Q6 A and B)
boolean
Item
Sites of progression, lung
text
CL.4
Code List
Sites of progression, lung
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, Lymph nodes (distant)
text
CL.5
Code List
Sites of progression, Lymph nodes (distant)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, pleural
text
CL.6
Code List
Sites of progression, pleural
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, adrenals
text
CL.7
Code List
Sites of progression, adrenals
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, liver
text
CL.8
Code List
Sites of progression, liver
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, bone
text
CL.9
Code List
Sites of progression, bone
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, CNS (Brain)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25331 (NCI Thesaurus Property)
C12438 (NCI Thesaurus ObjectClass)
C0927232 (UMLS 2011AA ObjectClass)
CL.10
Code List
Sites of progression, CNS (Brain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
ProgressionDate
Item
CNS (Brain) Date
date
Item
Sites of progression, Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
CL.11
Code List
Sites of progression, Other Specify
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
ProgressionSite,Other
Item
Site of progression, other specify
text
ProgressionAssessmentMethod
Item
PROGRESSION ASSESSMENT
float
Item
HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?
text
CL.13
Code List
HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
NewPrimarySite
Item
NEW PRIMARY SITE
text
NewPrimary,HistologicType
Item
NEW PRIMARY HISTOLOGIC TYPE
text
NewPrimaryCancerDate
Item
DATE OF DIAGNOSIS
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
text
CL.14
Code List
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol RT
text
CL.15
Code List
Non-Protocol RT
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Item
Non-Protocol Surgery
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
CL.16
Code List
Non-Protocol Surgery
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol Chemotherapy
text
CL.17
Code List
Non-Protocol Chemotherapy
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Other Non-Protocol therapy
text
CL.18
Code List
Other Non-Protocol therapy
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
OtherNon-ProtocolTherapyName
Item
Specify other
text
AmendedDataInd
Item
Revised
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
IMTCODETOXICITYCODEBASEDONCTEPTOXICITYTERM
Item
IMT CODE TOXICITY CODE BASED ON CTEP TOXICITY TERM
text
CTCAdverseEventTerm
Item
TERM
text
Item
GENERAL TOXICITY CATEGORY
text
CL.19
Code List
GENERAL TOXICITY CATEGORY
CL Item
Allergy / Immunology (Allergy / Immunology)
CL Item
Auditory/Hearing (Auditory/Hearing)
CL Item
Blood/Bone marrow (Blood/Bone marrow)
CL Item
Cardiovascular (Arrhythmia) (Cardiovascular (Arrhythmia))
CL Item
Cardiovascular (General) (Cardiovascular (General))
CL Item
Coagulation (Coagulation)
CL Item
Constitutional Symptoms (Constitutional Symptoms)
CL Item
Dermatology/Skin (Dermatology/Skin)
CL Item
Endocrine (Endocrine)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Hemorrhage (Hemorrhage)
CL Item
Hepatic (Hepatic)
CL Item
Infection/Febrile Neutropenia (Infection/Febrile Neutropenia)
CL Item
Lymphatics (Lymphatics)
CL Item
Metabolic/Laboratory (Metabolic/Laboratory)
CL Item
Musculoskeletal (Musculoskeletal)
CL Item
Neurology (Neurology)
CL Item
Ocular/Visual (Ocular/Visual)
CL Item
Pain (Pain)
CL Item
Pulmonary (Pulmonary)
CL Item
Renal/Genitourinary (Renal/Genitourinary)
CL Item
Second Malignancy (Second Malignancy)
CL Item
Sexual/Reproductive Function (Sexual/Reproductive Function)
CL Item
Syndromes (Syndromes)
CTCAdverseEventGrade
Item
SEVERITY GRADE
text
DATEOF1STOCCURRENCEOFGRADE=>3
Item
DATE OF 1ST OCCURRENCE OF GRADE=>3
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
ATTRIBUTION
text
CL.20
Code List
ATTRIBUTION
CL Item
Radiotherapy only (Brain) (Radiotherapy only (Brain))
CL Item
Other cause, specify in "Description" (Other cause, specify in "Description")
CL Item
Unknown (Unknown)
DESCRIPTION
Item
DESCRIPTION
text
HQUse
Item
HQ Use
text
Item Group
Comments
Comments
Item
Comments
text
SignatureofPersonCompletingThisForm
Item
Signature of Person Completing This Form
text
FormCompletionDate,Original
Item
Date
date
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial