ID

1063

Description

Gynecologic Procedures Form (Form 24-GYN) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12178AE-C51B-4967-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12178AE-C51B-4967-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

August 26, 2012

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Gynecologic Procedures Form (Form 24-GYN) - 2074074v3.0

English

GYNECOLOGIC PROCEDURES FORM (Form 24-GYN) Instructions: Complete this form if patient had gynecologic surgery, procedures and/or diagnostic imaging (excluding PAP smears and procedures related to diagnosis of cervical carcinoma in situ). Submit with the next scheduled Follow-Up (24-E) Form. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 forms  
Report All Gynecologic Procedures Which Apply:
Description

Report All Gynecologic Procedures Which Apply:

Transvaginal ultrasound Date (D M Y)
Description

TransvaginalultrasoundDate

Data type

text

Abdominal/pelvic ultrasound Date (D M Y)
Description

DiagnosticImagingAbdominalPelvicUltrasoundImagingPerformedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C25342
UMLS 2011AA Property
C0000726
NCI Thesaurus Property
C17230
UMLS 2011AA Property
C0041618
NCI Thesaurus Property
C25399
UMLS 2011AA Property
C0030797
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Other imaging Date (D M Y)
Description

OtherimagingDate

Data type

text

Other imaging, specify site and type of image
Description

Otherimaging,specifysiteandtypeofimage

Data type

text

Screening endometrial sampling Date (D M Y)
Description

Endometrialsamplingdate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Hysterectomy (date) (D M Y)
Description

HysterectomyPerformedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15256
UMLS 2011AA ObjectClass
C0020699
Unilateral oophorectomy Date (D M Y)
Description

UnilateralOophorectomyPerformedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C28012
UMLS 2011AA ObjectClass
C0205092
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15291
UMLS 2011AA ObjectClass
C0029936
Bilateral oophorectomy Date (D M Y)
Description

BilateraloophorectomyDate

Data type

text

Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
Description

Reasonhysterectomyoroophorectomywasdone

Data type

text

Other, specify (hysterectomy done)
Description

HysterectomyPerformedSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15256
UMLS 2011AA ObjectClass
C0020699
Date (day month year)
Description

InvestigatorSignatureDate

Data type

date

Date (day month year)
Description

InvestigatorSignatureDate

Data type

date

Pathologic Diagnosis
Description

PathologicDiagnosis

Data type

text

Ccrr Module For Gynecologic Procedures Form (form 24-gyn)
Description

Ccrr Module For Gynecologic Procedures Form (form 24-gyn)

Patient ID Number (Study No.)
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (f m fl sl)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Patient's Date of Birth (day)
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Participating Center/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Center Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
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Similar models

GYNECOLOGIC PROCEDURES FORM (Form 24-GYN) Instructions: Complete this form if patient had gynecologic surgery, procedures and/or diagnostic imaging (excluding PAP smears and procedures related to diagnosis of cervical carcinoma in situ). Submit with the next scheduled Follow-Up (24-E) Form. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Report All Gynecologic Procedures Which Apply:
TransvaginalultrasoundDate
Item
Transvaginal ultrasound Date (D M Y)
text
DiagnosticImagingAbdominalPelvicUltrasoundImagingPerformedDate
Item
Abdominal/pelvic ultrasound Date (D M Y)
date
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25342 (NCI Thesaurus Property)
C0000726 (UMLS 2011AA Property)
C17230 (NCI Thesaurus Property)
C0041618 (UMLS 2011AA Property)
C25399 (NCI Thesaurus Property)
C0030797 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
OtherimagingDate
Item
Other imaging Date (D M Y)
text
Otherimaging,specifysiteandtypeofimage
Item
Other imaging, specify site and type of image
text
Endometrialsamplingdate
Item
Screening endometrial sampling Date (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
HysterectomyPerformedDate
Item
Hysterectomy (date) (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15256 (NCI Thesaurus ObjectClass)
C0020699 (UMLS 2011AA ObjectClass)
UnilateralOophorectomyPerformedDate
Item
Unilateral oophorectomy Date (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C28012 (NCI Thesaurus ObjectClass)
C0205092 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15291 (NCI Thesaurus ObjectClass)
C0029936 (UMLS 2011AA ObjectClass)
BilateraloophorectomyDate
Item
Bilateral oophorectomy Date (D M Y)
text
Item
Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
text
CL.2
Code List
Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
CL Item
Ovarian Cancer Prevention (Ovarian cancer prevention)
CL Item
Breast Cancer Prevention (Breast cancer prevention)
C15553 (NCI Thesaurus)
C0281189 (UMLS 2011AA)
CL Item
Benign Gynecologic Condition (Benign gynecologic condition)
CL Item
Pre-malignancy (Pre-malignancy)
CL Item
Borderline Ovarian Tumor (Borderline ovarian tumor)
CL046614 (NCI Metathesaurus)
CL Item
Invasive Cancer (Invasive cancer)
CL Item
Other, Specify (Other, specify)
HysterectomyPerformedSpecify
Item
Other, specify (hysterectomy done)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15256 (NCI Thesaurus ObjectClass)
C0020699 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date (day month year)
date
InvestigatorSignatureDate
Item
Date (day month year)
date
Item
Pathologic Diagnosis
text
CL.1
Code List
Pathologic Diagnosis
CL Item
Negative (Negative)
CL Item
Invasive cancer (Invasive cancer)
CL Item
In situ cancer (In situ cancer)
CL Item
Simple cystic hyperplasia without atypia (Simple cystic hyperplasia without atypia)
CL Item
Simple cystic hyperplasia with atypia (Simple cystic hyperplasia with atypia)
CL Item
Complex/adenomatous hyperplasia without atypia (Complex/adenomatous hyperplasia without atypia)
CL Item
Complex/adenomatoushyperplasia with atypia (Complex/adenomatoushyperplasia with atypia)
CL Item
Non-diagnostic (Non-diagnostic)
Item Group
Ccrr Module For Gynecologic Procedures Form (form 24-gyn)
PatientStudyID,CoordinatingGroup
Item
Patient ID Number (Study No.)
text
PatientInitialsName
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientBirthDate
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
MainMemberInstitution/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
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