ID

10612

Description

NSABP PROTOCOL B-35 Treatment Form for Tamoxifen/Anastrozole NCT00053898 Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A051E957-2260-0392-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A051E957-2260-0392-E034-080020C9C0E0

Keywords

  1. 8/26/12 8/26/12 -
  2. 5/22/15 5/22/15 -
  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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NSABP PROTOCOL B-35 Treatment Form for Tamoxifen/Anastrozole NCT00053898

Form T (04-30-2002) Submit this form when Tamoxifen/Anastrozole therapy has ended or if the patient did not begin Tamoxifen/Anastrozole.

Header Module
Description

Header Module

First Three Letters of Patient's Last Name
Description

FirstThreeLettersofPatient'sLastName

Data type

text

Patient Study ID
Description

PatientStudyID

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Affiliate Name
Description

AffiliateName

Data type

text

Person Completing Form Last Name
Description

PersonCompletingForm,LastName

Data type

text

Person Completing Form First Name
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Person Completing Form Phone
Description

PersonCompletingForm,Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Are data amended? (If Yes, circle the amended items in red.)
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Summary Of Tamoxifen/anastrozole Administration
Description

Summary Of Tamoxifen/anastrozole Administration

Treatment Begin Date (0=not begun Month Day Year)
Description

TreatmentBeginDate

Data type

date

Treatment End Date (0=not begun Month Day Year )
Description

TreatmentEndDate

Data type

date

Reason for end of treatment
Description

Reason for end of treatment

Reason Treatment Ended (Select the reason that best explains why treatment has ended, or why the patient did not begin treatment.)
Description

OffTreatmentReason

Data type

text

Other
Description

OffTreatmentReason,Other

Data type

text

Similar models

Form T (04-30-2002) Submit this form when Tamoxifen/Anastrozole therapy has ended or if the patient did not begin Tamoxifen/Anastrozole.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
FirstThreeLettersofPatient'sLastName
Item
First Three Letters of Patient's Last Name
text
PatientStudyID
Item
Patient Study ID
text
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PersonCompletingForm,LastName
Item
Person Completing Form Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PersonCompletingForm,Phone
Item
Person Completing Form Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Are data amended? (If Yes, circle the amended items in red.)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Code List
Are data amended? (If Yes, circle the amended items in red.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Summary Of Tamoxifen/anastrozole Administration
TreatmentBeginDate
Item
Treatment Begin Date (0=not begun Month Day Year)
date
TreatmentEndDate
Item
Treatment End Date (0=not begun Month Day Year )
date
Item Group
Reason for end of treatment
Item
Reason Treatment Ended (Select the reason that best explains why treatment has ended, or why the patient did not begin treatment.)
text
Code List
Reason Treatment Ended (Select the reason that best explains why treatment has ended, or why the patient did not begin treatment.)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Toxicity/side Effects/complications (Toxicity/Side effects/Complications)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Disease Progression, Relapse Prior To Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
OffTreatmentReason,Other
Item
Other
text

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