Informatie:
Fout:
ID
10613
Beschrijving
CALGB: ADJUVANT RADIOTHERAPY REPORT FORM NCT00024102 Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50C8257-093C-33B9-E034-080020C9C0E0
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Versies (3)
- 26-08-12 26-08-12 -
- 22-05-15 22-05-15 -
- 03-06-15 03-06-15 -
Geüploaded op
3 juni 2015
DOI
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Licentie
Creative Commons BY-NC 3.0 Legacy
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CALGB: ADJUVANT RADIOTHERAPY REPORT FORM NCT00024102
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item
Has the patient received adjuvant therapy? (prior to diagnosis of recurrence or second primary cancer)
text
Code List
Has the patient received adjuvant therapy? (prior to diagnosis of recurrence or second primary cancer)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
AdjuvantRTBeginDate
Item
Date adjuvant radiation therapy started (M)
date
AdjuvantRTEndDate
Item
Date adjuvant radiation therapy ended (M)
date
CL Item
In-breast Radiotherapy Following Breast-conserving Surgery (In-breast radiotherapy following breast-conserving surgery)
CL Item
In-breast And Regional Radiotherapy Following Breast-conserving Surgery (In-breast and regional radiotherapy following breast-conserving surgery)
CL Item
Any Post-mastectomy Radiotherapy (Any post-mastectomy radiotherapy)
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed
date