ID

10590

Descrição

CALGB: 80101 Follow-up/Relapse Form NCT00052910 Chemotherapy and Radiation Therapy After Surgery in Treating Patients With Stomach or Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A3614107-525D-15BB-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A3614107-525D-15BB-E034-080020C9C0E0

Palavras-chave

Versões (3)
  1. 19/09/2012 19/09/2012 -
  2. 28/05/2015 28/05/2015 -
  3. 03/06/2015 03/06/2015 -
Transferido a

3 de junho de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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CALGB: 80101 Follow-up/Relapse Form NCT00052910

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: CALGB: 80101 Follow-up/Relapse Form
    1. No Instruction available.
CALGB clinical trial administrative data
Descrição

CALGB clinical trial administrative data

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBProtocolNumber

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Reporting period start date
Descrição

IntervalReportFromDate

Tipo de dados

date

To: (Date of Last contact or death)
Descrição

DeathDate/LastContactDate

Tipo de dados

date

Are data amended?
Descrição

AmendedDataInd

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
patient demographics
Descrição

patient demographics

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

Participating Group
Descrição

ParticipatingGroup

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital No
Descrição

PatientHospitalNumber

Tipo de dados

text

Participating Group Protocol No
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Institution/Affiliate
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

Participating Group Patient ID
Descrição

ParticipatingGroupPatientID

Tipo de dados

text

Patient's vital status (mark one with an X)
Descrição

Patient'sVitalStatus

Tipo de dados

text

Primary cause of death (mark one with an X)
Descrição

DeathReason

Tipo de dados

text

Due to other cause, specify
Descrição

DeathReason,Specify

Tipo de dados

text

Notice Of Progression/relapse
Descrição

Notice Of Progression/relapse

Has the patient developed a progression (or relapse) during this time period that has not been previously reported?
Descrição

DiseaseRelapseProgressionInd-3

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C38155
UMLS 2011AA Property
C0277556
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus Property
C19987
UMLS 2011AA Property
C0242656
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Date progressive or recurrent disease diagnosed
Descrição

Dateprogressiveorrecurrentdiseasediagnosed

Tipo de dados

text

Site(s) of progression/relapse (mark all that apply with an X)
Descrição

Site(s)ofprogression/relapse

Tipo de dados

text

Other, specify (sites of progression)
Descrição

Other,specify(sitesofprogression)

Tipo de dados

text

Lymph nodes, specify site
Descrição

ProgressionSite,LymphNodes

Tipo de dados

text

Stat Use Only
Descrição

Stat Use Only

Location of relapse
Descrição

RelapseLocationType

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C18265
Notice Of New Primary
Descrição

Notice Of New Primary

Has a new primary cancer or AML/MDS been diagnosed that has not been previously reported?
Descrição

Hasanewprimarycancerormyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?

Tipo de dados

text

Date of diagnosis
Descrição

NewPrimaryCancerDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Site(s) of new primary
Descrição

NewPrimarySite

Tipo de dados

text

Completed by (First Name, Last Name)
Descrição

CompletedBy

Tipo de dados

text

Date completed
Descrição

DateCompleted

Tipo de dados

date

Ccrr Module For Calgb: 80101 Follow-up/relapse Form
Descrição

Ccrr Module For Calgb: 80101 Follow-up/relapse Form

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: CALGB: 80101 Follow-up/Relapse Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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
IntervalReportFromDate
Item
Reporting period start date
date
DeathDate/LastContactDate
Item
To: (Date of Last contact or death)
date
Item
Are data amended?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
patient demographics
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital No
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
Item
Patient's vital status (mark one with an X)
text
CL.2
Code List
Patient's vital status (mark one with an X)
CL Item
Alive (Alive)
CL Item
Dead (Dead)
CL Item
Lost (Lost)
Item
Primary cause of death (mark one with an X)
text
CL.3
Code List
Primary cause of death (mark one with an X)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Other Cause, Specify (Due to other cause, specify)
DeathReason,Specify
Item
Due to other cause, specify
text
Item Group
Notice Of Progression/relapse
Item
Has the patient developed a progression (or relapse) during this time period that has not been previously reported?
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C38155 (NCI Thesaurus Property)
C0277556 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C19987 (NCI Thesaurus Property)
C0242656 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.4
Code List
Has the patient developed a progression (or relapse) during this time period 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)
Dateprogressiveorrecurrentdiseasediagnosed
Item
Date progressive or recurrent disease diagnosed
text
Item
Site(s) of progression/relapse (mark all that apply with an X)
text
CL.5
Code List
Site(s) of progression/relapse (mark all that apply with an X)
CL Item
Anastomosis (Anastomosis)
C15609 (NCI Thesaurus)
C0677554 (UMLS 2011AA)
CL Item
Tumor Bed/regional Organs (Tumor bed/regional organs)
CL Item
Residual Stomach (Residual stomach)
CL Item
Lymph Nodes (Lymph nodes)
CL Item
Mesentery/peritoneum (Mesentery/peritoneum)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Cns/brain (CNS/Brain)
CL Item
Other, Specify (Other, specify)
Other,specify(sitesofprogression)
Item
Other, specify (sites of progression)
text
ProgressionSite,LymphNodes
Item
Lymph nodes, specify site
text
Item Group
Stat Use Only
Item
Location of relapse
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C18265 (NCI Thesaurus ObjectClass)
CL.6
Code List
Location of relapse
CL Item
Local-regional (Local-regional)
C25388 (NCI Thesaurus)
C1947913 (UMLS 2011AA)
CL Item
Distant (Distant)
C25321 (NCI Thesaurus)
C0443203 (UMLS 2011AA)
Item Group
Notice Of New Primary
Item
Has a new primary cancer or AML/MDS been diagnosed that has not been previously reported?
text
CL.7
Code List
Has a new primary cancer or AML/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)
NewPrimaryCancerDate
Item
Date of diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
Site(s) of new primary
text
CompletedBy
Item
Completed by (First Name, Last Name)
text
DateCompleted
Item
Date completed
date
Item Group
Ccrr Module For Calgb: 80101 Follow-up/relapse Form
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