ID
10639
Beskrivning
CALGB: 49903 ADVERSE EVENT FORM NCT00053339 Trastuzumab With or Without Tamoxifen in Treating Women With Progressive Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D2363-5625-477E-E034-0003BA0B1A09
Länk
Nyckelord
Versioner (2)
- 2014-12-18 2014-12-18 - Martin Dugas
- 2015-06-03 2015-06-03 -
Uppladdad den
3 juni 2015
DOI
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Licens
Creative Commons BY-NC 3.0 Legacy
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CALGB: 49903 ADVERSE EVENT FORM NCT00053339
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.
Beskrivning
Patient demographics
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Patient'sName
Datatyp
text
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ParticipatingGroup
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
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PatientHospitalNumber
Datatyp
text
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ParticipatingGroupProtocolNo.
Datatyp
text
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AffiliateName
Datatyp
text
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ParticipatingGroupPatientID
Datatyp
text
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ADR Report
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Expected Adverse Events
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IMTCodeduplicate
Datatyp
text
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CTCAdverseEventTerm
Datatyp
text
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CTCAdverseEventGrade
Datatyp
text
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CTCAdverseEventAttributionCode
Datatyp
text
Beskrivning
Person Completing Form
Beskrivning
Ccrr Module For Calgb: 49903 Adverse Event Form
Similar models
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.
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1521800 (UMLS 2011AA ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0445356 (UMLS 2011AA)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)