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10621

Beschreibung

CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION NCT00016276 Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8542-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8542-227A-E034-080020C9C0E0

Stichworte

Versionen (4)
  1. 26.08.12 26.08.12 -
  2. 22.05.15 22.05.15 -
  3. 03.06.15 03.06.15 -
  4. 20.09.21 20.09.21 -
Hochgeladen am

3. Juni 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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    CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION NCT00016276

    Englisch

    No Instruction available.

    1 Formulare  
    1. StudyEvent: CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION
      1. No Instruction available.
    CALGB Information
    Beschreibung

    CALGB Information

    CALGB Patient Number
    Beschreibung

    CALGBPatientNumber

    Datentyp

    text

    Participating Group Code Patient No.
    Beschreibung

    ParticipatingGroupCodePatientNo.

    Datentyp

    text

    Patient Medical Record No.
    Beschreibung

    PatientMedicalRecordNo.

    Datentyp

    text

    Participating Group Code
    Beschreibung

    ParticipatingGroupCode

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    Main Member Institution/Affiliate
    Beschreibung

    MainMemberInstitution/Affiliate

    Datentyp

    text

    Physician of Record
    Beschreibung

    RegisteredInvestigator

    Datentyp

    text

    FAX
    Beschreibung

    FAX

    Datentyp

    text

    Phone
    Beschreibung

    Phone

    Datentyp

    text

    Protocol Administration
    Beschreibung

    Protocol Administration

    IRB/REB Approval Date
    Beschreibung

    IRB/REBApprovalDate

    Datentyp

    text

    Person Completing Form, Last Name
    Beschreibung

    PersonCompletingForm,LastName

    Datentyp

    text

    Consent Form Date
    Beschreibung

    ConsentFormDate

    Datentyp

    text

    Person Completing Form, first Name
    Beschreibung

    PersonCompletingForm,FirstName

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Projected Start Date
    Beschreibung

    ProjectedStartDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25431
    UMLS 2011AA ValueDomain
    C0439659
    NCI Thesaurus ValueDomain
    C25631
    Person Phone
    Beschreibung

    PersonPhone

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    Person Fax
    Beschreibung

    PersonFax

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25210
    UMLS 2011AA Property
    C0085205
    Date of Registration
    Beschreibung

    RegistrationDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Registrar
    Beschreibung

    Registrar

    Datentyp

    text

    Patient Demographics / Pre U Treatment Characteristics
    Beschreibung

    Patient Demographics / Pre U Treatment Characteristics

    Patient Name (l,f,m.i.)
    Beschreibung

    PatientName

    Datentyp

    text

    Social Security Number (USA Only)
    Beschreibung

    PatientSocialSecurityNumber

    Datentyp

    double

    Patient Race/ Ethnicity
    Beschreibung

    PatientRace/Ethnicity

    Datentyp

    text

    Sex
    Beschreibung

    Sex

    Datentyp

    text

    Birthdate
    Beschreibung

    Birthdate

    Datentyp

    text

    Method of Payment
    Beschreibung

    MethodofPayment

    Datentyp

    text

    Zip Code
    Beschreibung

    ZipCode

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    Performance Status
    Beschreibung

    PerformanceStatus

    Datentyp

    text

    Pt Height (cm)
    Beschreibung

    PtHeight

    Datentyp

    text

    Pt Weight (kg)
    Beschreibung

    PtWeight

    Datentyp

    text

    BSA (m2)
    Beschreibung

    BSA

    Datentyp

    text

    Patient Eligible?
    Beschreibung

    PatientEligible?

    Datentyp

    text

    Name of medical oncologist
    Beschreibung

    Nameofmedicaloncologist

    Datentyp

    text

    Name of RT oncologist
    Beschreibung

    NameofRToncologist

    Datentyp

    text

    RN Coordinator
    Beschreibung

    RNCoordinator

    Datentyp

    text

    Surgeon
    Beschreibung

    Surgeon

    Datentyp

    text

    Stratification Factors
    Beschreibung

    Stratification Factors

    Disease Type
    Beschreibung

    DiseaseType

    Datentyp

    text

    ASSIGNED TREATMENT ARM
    Beschreibung

    ProtocolTreatmentArmAssignmentText

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass
    C42651
    UMLS 2011AA ObjectClass
    C0442711
    NCI Thesaurus Property
    C32141
    UMLS 2011AA Property
    C1140618
    NCI Thesaurus Property
    C25426
    UMLS 2011AA Property
    C1516050
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    Patient?s initial consent given for specimen use for research on the patient?s cancer?
    Beschreibung

    Patient?sinitialconsentgivenforspecimenuseforresearchonthepatient?scancer?

    Datentyp

    text

    Patient?s initial consent given for specimen use for research unrelated to the patient?s cancer?
    Beschreibung

    Patient?sinitialconsentgivenforspecimenuseforresearchunrelatedtothepatient?scancer?

    Datentyp

    text

    Patient?s initial consent given for further contact regarding specimen?
    Beschreibung

    Patient'sinitialconsentgivenforfurthercontactregardingspecimen?

    Datentyp

    text

    Zum Seitenanfang zurückkehren

    Ähnliche Modelle

    No Instruction available.

    1 Formulare
    1. StudyEvent: CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    CALGB Information
    CALGBPatientNumber
    Item
    CALGB Patient Number
    text
    ParticipatingGroupCodePatientNo.
    Item
    Participating Group Code Patient No.
    text
    PatientMedicalRecordNo.
    Item
    Patient Medical Record No.
    text
    ParticipatingGroupCode
    Item
    Participating Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    MainMemberInstitution/Affiliate
    Item
    Main Member Institution/Affiliate
    text
    RegisteredInvestigator
    Item
    Physician of Record
    text
    FAX
    Item
    FAX
    text
    Phone
    Item
    Phone
    text
    Item Group
    Protocol Administration
    IRB/REBApprovalDate
    Item
    IRB/REB Approval Date
    text
    PersonCompletingForm,LastName
    Item
    Person Completing Form, Last Name
    text
    ConsentFormDate
    Item
    Consent Form Date
    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)
    ProjectedStartDate
    Item
    Projected Start Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25431 (NCI Thesaurus ValueDomain)
    C0439659 (UMLS 2011AA ValueDomain)
    C25631 (NCI Thesaurus ValueDomain)
    PersonPhone
    Item
    Person Phone
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    PersonFax
    Item
    Person Fax
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25210 (NCI Thesaurus Property)
    C0085205 (UMLS 2011AA Property)
    RegistrationDate
    Item
    Date of Registration
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Registrar
    Item
    Registrar
    text
    Item Group
    Patient Demographics / Pre U Treatment Characteristics
    PatientName
    Item
    Patient Name (l,f,m.i.)
    text
    PatientSocialSecurityNumber
    Item
    Social Security Number (USA Only)
    double
    Item
    Patient Race/ Ethnicity
    text
    CL.1
    Code List
    Patient Race/ Ethnicity
    CL Item
    White (White)
    CL Item
    Hispanic (Hispanic)
    CL Item
    Black (Black)
    CL Item
    Oriental (Oriental)
    CL Item
    Native Hawaiian (Native Hawaiian)
    CL Item
    Native American (Native American)
    CL Item
    Indian (Indian)
    CL Item
    Filipino (Filipino)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Patient Refusal (Patient refusal)
    CL Item
    Institution Refusal (Institution refusal)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Sex
    text
    CL.2
    Code List
    Sex
    CL Item
    Male (M)
    C20197 (NCI Thesaurus)
    C0024554 (UMLS 2011AA)
    CL Item
    Female (F)
    C16576 (NCI Thesaurus)
    C0015780 (UMLS 2011AA)
    Birthdate
    Item
    Birthdate
    text
    Item
    Method of Payment
    text
    CL.3
    Code List
    Method of Payment
    CL Item
    Private Insurance (Private Insurance)
    CL Item
    Medicare And Private Insurance (Medicare and Private Insurance)
    CL Item
    Medicaid (Medicaid)
    C0025071 (NCI Metathesaurus)
    CL Item
    Medicaid And Medicare (Medicaid and Medicare)
    CL Item
    Millitary Or Veterans Administration (Millitary or Veterans Administration)
    CL Item
    Self Pay (Self Pay)
    CL Item
    No Means Of Payment (No means of payment)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Zip Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Zip Code
    CL Item
    (usa Only) ((USA Only))
    Item
    Performance Status
    text
    CL.5
    Code List
    Performance Status
    CL Item
    Fully Active, Able To Carry On All Pre-disease Performance Without Restriction, (Fully active, able to carry on all pre-disease performance without restriction,)
    CL Item
    Restricted In Physically Strenuous Activity But Ambulatory, (Restricted in physically strenuous activity but ambulatory,)
    CL Item
    Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities, (Ambulatory and capable of all selfcare but unable to carry out any work activities,)
    CL Item
    Capable Of Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours, (Capable of limited selfcare, confined to bed or chair more than 50% of waking hours,)
    CL Item
    Completely Disabled (Completely disabled)
    PtHeight
    Item
    Pt Height (cm)
    text
    PtWeight
    Item
    Pt Weight (kg)
    text
    BSA
    Item
    BSA (m2)
    text
    Item
    Patient Eligible?
    text
    CL.6
    Code List
    Patient Eligible?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, All Requirements Confirmed (Yes, all requirements confirmed)
    Nameofmedicaloncologist
    Item
    Name of medical oncologist
    text
    NameofRToncologist
    Item
    Name of RT oncologist
    text
    RNCoordinator
    Item
    RN Coordinator
    text
    Surgeon
    Item
    Surgeon
    text
    Item Group
    Stratification Factors
    Item
    Disease Type
    text
    CL.7
    Code List
    Disease Type
    CL Item
    Inflammatory (Inflammatory)
    C25535 (NCI Thesaurus)
    C0333348 (UMLS 2011AA)
    CL Item
    Noninflammatory, Inoperable Stage Iii/regional Stage Iv (Noninflammatory, inoperable Stage III/regional Stage IV)
    CL Item
    Operable Stage Iii (Operable Stage III)
    ProtocolTreatmentArmAssignmentText
    Item
    ASSIGNED TREATMENT ARM
    text
    C15368 (NCI Thesaurus ObjectClass)
    C42651 (NCI Thesaurus ObjectClass)
    C0442711 (UMLS 2011AA ObjectClass)
    C32141 (NCI Thesaurus Property)
    C1140618 (UMLS 2011AA Property)
    C25426 (NCI Thesaurus Property)
    C1516050 (UMLS 2011AA Property)
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    Item
    Patient?s initial consent given for specimen use for research on the patient?s cancer?
    text
    CL.8
    Code List
    Patient?s initial consent given for specimen use for research on the patient?s cancer?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Patient?s initial consent given for specimen use for research unrelated to the patient?s cancer?
    text
    CL.9
    Code List
    Patient?s initial consent given for specimen use for research unrelated to the patient?s cancer?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Patient?s initial consent given for further contact regarding specimen?
    text
    CL.10
    Code List
    Patient?s initial consent given for further contact regarding specimen?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Zum Seitenanfang zurückkehren 

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