ID

10572

Beschreibung

S0023 LUNG CARCINOMA FOLLOW UP FORM NCT00020709 S0023: Combination Chemo Plus RT With or Without Gefitinib in Treating Patients With Unresectable Stage III NSCLC Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CB6D1D2-A964-34E4-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CB6D1D2-A964-34E4-E034-080020C9C0E0

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 -
  2. 28.05.15 28.05.15 -
  3. 03.06.15 03.06.15 -
Hochgeladen am

3. Juni 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.

S0023 LUNG CARCINOMA FOLLOW UP FORM NCT00020709

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: S0023 LUNG CARCINOMA FOLLOW UP FORM
    1. No Instruction available.
SWOG clinical trial administrative data
Beschreibung

SWOG clinical trial administrative data

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Patient Initials (L, F,M)
Beschreibung

PatientInitials

Datentyp

text

Institution / Affiliate
Beschreibung

Institution/Affiliate

Datentyp

text

Physician
Beschreibung

Physician

Datentyp

text

Group Name (Groups other than SWOG )
Beschreibung

GroupName

Datentyp

text

Study No. (Groups other than SWOG )
Beschreibung

StudyNo.

Datentyp

double

Pt. ID (Groups other than SWOG )
Beschreibung

Pt.ID

Datentyp

text

Vital Status
Beschreibung

Vital Status

Vital Status
Beschreibung

VitalStatus:

Datentyp

text

Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
Beschreibung

Dateoflastcontactordeath:

Datentyp

text

Disease Follow Up Status
Beschreibung

Disease Follow Up Status

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Beschreibung

Hasthepatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?

Datentyp

text

If Yes, Date of Last Clinical Assessment
Beschreibung

IfYes,DateofLastClinicalAssessment:

Datentyp

text

Has the patient developed a first relapse or progression that has not been previously reported?
Beschreibung

Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?

Datentyp

text

If Yes, Date of Relapse or Progression
Beschreibung

IfYes,DateofRelapseorProgression:

Datentyp

text

If yes, please submit the Lung Carcinoma First Site(s) of Progression or Relapse Form.
Beschreibung

Ifyes,pleasesubmittheLungCarcinomaFirstSite(s)ofProgressionorRelapseForm.

Datentyp

text

Notice Of New Primary
Beschreibung

Notice Of New Primary

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Beschreibung

Hasanewprimarycancerormyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?

Datentyp

text

If Yes, Date of Diagnosis
Beschreibung

IfYes,DateofDiagnosis:

Datentyp

text

New Primary Site
Beschreibung

NewPrimarySite:

Datentyp

text

Non-protocol Treatment
Beschreibung

Non-protocol Treatment

Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
Beschreibung

Hasthepatientreceivedanynon-protocolcancertherapy(priortoprogression/relapse)notpreviouslyreported?

Datentyp

text

If Yes, Date of First Non-Protocol Therapy
Beschreibung

IfYes,DateofFirstNon-ProtocolTherapy:

Datentyp

text

Agents
Beschreibung

Agents:

Datentyp

text

Long Term Toxicity
Beschreibung

Long Term Toxicity

Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade =>3) long term toxicity that has not been previously reported?
Beschreibung

Hasthepatientexperienced(priortotreatmentforprogressionorrelapseorasecondprimary,andpriortonon-protocoltreatment)anysevere(grade=>3)longtermtoxicitythathasnotbeenpreviouslyreported?

Datentyp

text

If Yes, Toxicities and Grades
Beschreibung

IfYes,ToxicitiesandGrades:

Datentyp

text

Notes
Beschreibung

Notes

Notes
Beschreibung

Notes

Datentyp

text

Zum Seitenanfang zurückkehren

Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: S0023 LUNG CARCINOMA FOLLOW UP FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
PatientInitials
Item
Patient Initials (L, F,M)
text
Institution/Affiliate
Item
Institution / Affiliate
text
Physician
Item
Physician
text
GroupName
Item
Group Name (Groups other than SWOG )
text
StudyNo.
Item
Study No. (Groups other than SWOG )
double
Pt.ID
Item
Pt. ID (Groups other than SWOG )
text
Item Group
Vital Status
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Dateoflastcontactordeath:
Item
Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
text
Item Group
Disease Follow Up Status
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
text
CL.2
Code List
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
CL Item
No (No)
CL Item
Yes (Yes)
IfYes,DateofLastClinicalAssessment:
Item
If Yes, Date of Last Clinical Assessment
text
Item
Has the patient developed a first relapse or progression that has not been previously reported?
text
CL.3
Code List
Has the patient developed a first relapse or progression that has not been previously reported?
CL Item
No2007229 (No)
CL Item
Yes2007230 (Yes)
IfYes,DateofRelapseorProgression:
Item
If Yes, Date of Relapse or Progression
text
Ifyes,pleasesubmittheLungCarcinomaFirstSite(s)ofProgressionorRelapseForm.
Item
If yes, please submit the Lung Carcinoma First Site(s) of Progression or Relapse Form.
text
Item Group
Notice Of New Primary
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
text
CL.4
Code List
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
CL Item
No2007235 (No)
CL Item
Yes2007236 (Yes)
IfYes,DateofDiagnosis:
Item
If Yes, Date of Diagnosis
text
NewPrimarySite:
Item
New Primary Site
text
Item Group
Non-protocol Treatment
Item
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
text
CL.5
Code List
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
CL Item
No2007241 (No)
CL Item
Yes2007242 (Yes)
IfYes,DateofFirstNon-ProtocolTherapy:
Item
If Yes, Date of First Non-Protocol Therapy
text
Agents:
Item
Agents
text
Item Group
Long Term Toxicity
Item
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade =>3) long term toxicity that has not been previously reported?
text
CL.6
Code List
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade =>3) long term toxicity that has not been previously reported?
CL Item
No2007247 (No)
CL Item
Yes2007248 (Yes)
IfYes,ToxicitiesandGrades:
Item
If Yes, Toxicities and Grades
text
Item Group
Notes
Notes
Item
Notes
text
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