ID

10621

Beschrijving

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

Trefwoorden

Versies (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 -
Geüploaded op

3 juni 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

  • Nieuwste
  • Oudste
  • Populair
  • Nieuwste
    • Nieuwste
    • Oudste
    • Populair

Geen commentaren

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION NCT00016276

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION
    1. No Instruction available.
CALGB Information
Beschrijving

CALGB Information

CALGB Patient Number
Beschrijving

CALGBPatientNumber

Datatype

text

Participating Group Code Patient No.
Beschrijving

ParticipatingGroupCodePatientNo.

Datatype

text

Patient Medical Record No.
Beschrijving

PatientMedicalRecordNo.

Datatype

text

Participating Group Code
Beschrijving

ParticipatingGroupCode

Datatype

text

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

MainMemberInstitution/Affiliate

Datatype

text

Physician of Record
Beschrijving

RegisteredInvestigator

Datatype

text

FAX
Beschrijving

FAX

Datatype

text

Phone
Beschrijving

Phone

Datatype

text

Protocol Administration
Beschrijving

Protocol Administration

IRB/REB Approval Date
Beschrijving

IRB/REBApprovalDate

Datatype

text

Person Completing Form, Last Name
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Consent Form Date
Beschrijving

ConsentFormDate

Datatype

text

Person Completing Form, first Name
Beschrijving

PersonCompletingForm,FirstName

Datatype

text

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

ProjectedStartDate

Datatype

date

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

PersonPhone

Datatype

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
Beschrijving

PersonFax

Datatype

text

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

RegistrationDate

Datatype

date

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

Registrar

Datatype

text

Patient Demographics / Pre U Treatment Characteristics
Beschrijving

Patient Demographics / Pre U Treatment Characteristics

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

PatientName

Datatype

text

Social Security Number (USA Only)
Beschrijving

PatientSocialSecurityNumber

Datatype

double

Patient Race/ Ethnicity
Beschrijving

PatientRace/Ethnicity

Datatype

text

Sex
Beschrijving

Sex

Datatype

text

Birthdate
Beschrijving

Birthdate

Datatype

text

Method of Payment
Beschrijving

MethodofPayment

Datatype

text

Zip Code
Beschrijving

ZipCode

Datatype

text

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

PerformanceStatus

Datatype

text

Pt Height (cm)
Beschrijving

PtHeight

Datatype

text

Pt Weight (kg)
Beschrijving

PtWeight

Datatype

text

BSA (m2)
Beschrijving

BSA

Datatype

text

Patient Eligible?
Beschrijving

PatientEligible?

Datatype

text

Name of medical oncologist
Beschrijving

Nameofmedicaloncologist

Datatype

text

Name of RT oncologist
Beschrijving

NameofRToncologist

Datatype

text

RN Coordinator
Beschrijving

RNCoordinator

Datatype

text

Surgeon
Beschrijving

Surgeon

Datatype

text

Stratification Factors
Beschrijving

Stratification Factors

Disease Type
Beschrijving

DiseaseType

Datatype

text

ASSIGNED TREATMENT ARM
Beschrijving

ProtocolTreatmentArmAssignmentText

Datatype

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?
Beschrijving

Patient?sinitialconsentgivenforspecimenuseforresearchonthepatient?scancer?

Datatype

text

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

Patient?sinitialconsentgivenforspecimenuseforresearchunrelatedtothepatient?scancer?

Datatype

text

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

Patient'sinitialconsentgivenforfurthercontactregardingspecimen?

Datatype

text

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial