ID
10705
Description
E5103 Disease and Vital Status Form NCT00433511 Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=22AFE3B9-AE28-56F9-E044-0003BA3F9857
Lien
Mots-clés
Versions (3)
- 26/08/2012 26/08/2012 -
- 08/01/2015 08/01/2015 - Martin Dugas
- 08/06/2015 08/06/2015 -
Téléchargé le
8 juin 2015
DOI
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Creative Commons BY-NC 3.0 Legacy
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E5103 Disease and Vital Status Form NCT00433511
Instructions: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule). Submit original to the ECOG Coordinating Center; Keep a copy for your files.
Description
Off Treatment
Description
PersonOff-TreatmentTimePeriodType
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
- C1948053
- NCI Thesaurus Property-2
- C25601
- UMLS 2011AA Property-2
- C1518544
- NCI Thesaurus Property-3
- C25207
- UMLS 2011AA Property-3
- C0040223
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
Description
Data amendment
Description
Data amended
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C0680532
- NCI Thesaurus ObjectClass
- C25474
- NCI Thesaurus Property
- C25416
Description
Data amended date
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0680532
- NCI Thesaurus ObjectClass
- C25474
- UMLS CUI-2
- C0011008
- NCI Thesaurus Property
- C25416
- NCI Thesaurus ValueDomain-2
- C25367
Description
Breast: Vital Status
Description
Patient Status
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-1
- C3846084
- NCI Thesaurus ValueDomain
- C18003
- NCI Thesaurus ValueDomain-2
- C25688
- NCI Thesaurus Property
- C25717
Description
Date last contact
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-1
- C0805839
- NCI Thesaurus Property
- C25461
- NCI Thesaurus Property-2
- C25551
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25367
Description
Primary Cause of Death
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS CUI-1
- C0007465
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C28554
- NCI Thesaurus ValueDomain-2
- C25251
Description
Cause of Death, specify
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS CUI-1
- C0007465
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C1521902
- NCI Thesaurus Property
- C28554
Description
Section II - Reporting Period
Description
Reporting Period Start Date
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25616
- UMLS CUI-1
- C2361257
- NCI Thesaurus Property-2
- C25651
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25431
Description
Reporting Period End Date
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C2361259
- NCI Thesaurus Property
- C25616
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property-2
- C25651
Description
Section Iii - New Primary Cancers
Description
NewCancerDiagnosisInd-3
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus ObjectClass
- C25586
- UMLS 2011AA ObjectClass
- C0205314
- NCI Thesaurus ObjectClass-2
- C9305
- UMLS 2011AA ObjectClass-2
- C0006826
- NCI Thesaurus Property
- C15220
- UMLS 2011AA Property
- C0011900
Description
NewCancerSiteText
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus ObjectClass
- C25586
- UMLS 2011AA ObjectClass
- C0205314
- NCI Thesaurus Property
- C25341
- UMLS 2011AA Property
- C0450429
- NCI Thesaurus ObjectClass-2
- C9305
- UMLS 2011AA ObjectClass-2
- C0006826
Description
Notice Of First Distance Recurrence
Description
RecurrentDiseaseFirstDistantDiagnosisInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C38155
- UMLS 2011AA ObjectClass
- C0277556
- NCI Thesaurus Property
- C25321
- UMLS 2011AA Property
- C0443203
- NCI Thesaurus Property-2
- C25509
- UMLS 2011AA Property-2
- C1279901
- NCI Thesaurus Property-3
- C15220
- UMLS 2011AA Property-3
- C0011900
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Section V - Disease Follow-up Status
Description
Documented clinical assessment for this cancer
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS CUI-1
- C1522577
- NCI Thesaurus Property
- C16033
- UMLS CUI-2
- C0006826
- NCI Thesaurus ObjectClass
- C9305
- NCI Thesaurus Property-2
- C25365
Description
CancerUnknownFollow-upAssessmentSpecify
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C9305
- UMLS 2011AA ObjectClass
- C0006826
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus Property-2
- C17998
- UMLS 2011AA Property-2
- C0439673
- NCI Thesaurus Property-3
- C16033
- UMLS 2011AA Property-3
- C1522577
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
Description
PatientPhysicalExaminationMostRecentDate
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus ValueDomain-2
- C25577
- UMLS 2011AA ValueDomain-2
- C1513491
Description
LaboratoryProcedureNotPerformedText
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus Property
- C25594
- UMLS 2011AA Property
- C1518422
- NCI Thesaurus Property-2
- C38000
- UMLS 2011AA Property-2
- C0884358
- NCI Thesaurus ObjectClass
- C25294
- UMLS 2011AA ObjectClass
- C0022885
Description
PatientChestRadiographyComputedTomographyAssessmentDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus Property-2
- C38103
- UMLS 2011AA Property-2
- C0039985
- NCI Thesaurus Property-3
- C17204
- UMLS 2011AA Property-3
- C0040405
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Evaluation method
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C2911685
- NCI Thesaurus ObjectClass
- C20989
- NCI Thesaurus Property
- C16847
Description
AssessmentImageReportingType
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus ValueDomain-2
- C25651
- UMLS 2011AA ValueDomain-2
- C0700287
- NCI Thesaurus Property
- C19477
- UMLS 2011AA Property
- C1704254
Description
MammogramPerformedDate
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C20178
- UMLS 2011AA ObjectClass
- C0024671
- NCI Thesaurus Property
- C38000
- UMLS 2011AA Property
- C0884358
Description
Iib - Local-regional Recurrence
Description
Follow-Up Date
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C9305
- UMLS CUI-1
- C3694716
- NCI Thesaurus Property
- C16033
- NCI Thesaurus Property-2
- C25365
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25367
Description
DataUnknownText
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus ObjectClass
- C25474
- UMLS 2011AA ObjectClass
- C1511726
- NCI Thesaurus Property
- C17998
- UMLS 2011AA Property
- C0439673
Description
Neoplasm Recurrence, locoregional
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C19987
- UMLS CUI-1
- C0027643
- NCI Thesaurus Property
- C25388
- NCI Thesaurus Property-2
- C25509
- NCI Thesaurus Property-3
- C15220
- NCI Thesaurus ValueDomain
- C38148
Description
RecurrentDiseaseFirstLocal-RegionalDiagnosisDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C38155
- UMLS 2011AA ObjectClass
- C0277556
- NCI Thesaurus Property
- C25388
- UMLS 2011AA Property
- C1947913
- NCI Thesaurus Property-2
- C25509
- UMLS 2011AA Property-2
- C1279901
- NCI Thesaurus Property-3
- C15220
- UMLS 2011AA Property-3
- C0011900
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Local-RegionalBreastAxillaProgressionInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C12971
- UMLS 2011AA ObjectClass
- C0006141
- NCI Thesaurus ObjectClass-2
- C25388
- UMLS 2011AA ObjectClass-2
- C1947913
- NCI Thesaurus Property
- C25331
- NCI Thesaurus Property-2
- C12674
- UMLS 2011AA Property
- C0004454
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Local-RegionalBreastAxillaryLymphNodeProgressionInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C12971
- UMLS 2011AA ObjectClass
- C0006141
- NCI Thesaurus ObjectClass-2
- C25388
- UMLS 2011AA ObjectClass-2
- C1947913
- NCI Thesaurus Property
- C25331
- NCI Thesaurus Property-2
- C12904
- UMLS 2011AA Property
- C0729594
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Local-RegionalBreastInfraclavicularLymphNodeProgressionInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C12971
- UMLS 2011AA ObjectClass
- C0006141
- NCI Thesaurus ObjectClass-2
- C25388
- UMLS 2011AA ObjectClass-2
- C1947913
- NCI Thesaurus Property
- C25331
- NCI Thesaurus Property-2
- C63705
- UMLS 2011AA Property
- C0229743
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Local-RegionalBreastInternalMammaryLymphNodeProgressionInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C12971
- UMLS 2011AA ObjectClass
- C0006141
- NCI Thesaurus ObjectClass-2
- C25388
- UMLS 2011AA ObjectClass-2
- C1947913
- NCI Thesaurus Property
- C25331
- NCI Thesaurus Property-2
- C32853
- UMLS 2011AA Property
- C0229755
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Local-RegionalBreastIpsilateralProgressionInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C12971
- UMLS 2011AA ObjectClass
- C0006141
- NCI Thesaurus ObjectClass-2
- C25388
- UMLS 2011AA ObjectClass-2
- C1947913
- NCI Thesaurus Property
- C25331
- NCI Thesaurus Property-2
- C25308
- UMLS 2011AA Property
- C0441989
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Local-RegionalBreastSupraclavicularLymphNodeProgressionInd-3
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C25331
- NCI Thesaurus ObjectClass
- C12971
- UMLS 2011AA ObjectClass
- C0006141
- NCI Thesaurus ObjectClass-2
- C25388
- UMLS 2011AA ObjectClass-2
- C1947913
- NCI Thesaurus Property-2
- C12903
- UMLS 2011AA Property
- C0229730
Description
DiagnosisMethodType
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C16847
- UMLS 2011AA Property
- C0449851
- NCI Thesaurus ObjectClass
- C15220
- UMLS 2011AA ObjectClass
- C0011900
Description
Evaluation method, specify
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS CUI-1
- C2911685
- NCI Thesaurus ObjectClass
- C20989
- UMLS CUI-2
- C1521902
- NCI Thesaurus Property
- C16847
Description
Iic - Distance Recurrence
Description
Neoplasm recurrence, Distal
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C19987
- UMLS CUI-1
- C0027627
- NCI Thesaurus Property
- C25321
- NCI Thesaurus Property-2
- C25509
- NCI Thesaurus Property-3
- C15220
- NCI Thesaurus ValueDomain
- C25180
Description
RecurrentDiseaseFirstDistantDiagnosisDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C38155
- UMLS 2011AA ObjectClass
- C0277556
- NCI Thesaurus Property
- C25321
- UMLS 2011AA Property
- C0443203
- NCI Thesaurus Property-2
- C25509
- UMLS 2011AA Property-2
- C1279901
- NCI Thesaurus Property-3
- C15220
- UMLS 2011AA Property-3
- C0011900
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
RecurrentDiseaseFirstDistantDiagnosisAnatomicSite
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C38155
- UMLS 2011AA ObjectClass
- C0277556
- NCI Thesaurus Property
- C25321
- UMLS 2011AA Property
- C0443203
- NCI Thesaurus Property-2
- C25509
- UMLS 2011AA Property-2
- C1279901
- NCI Thesaurus Property-3
- C15220
- UMLS 2011AA Property-3
- C0011900
- NCI Thesaurus ValueDomain
- C13717
- UMLS 2011AA ValueDomain
- C1515974
Description
DiagnosisMethodSpecify
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus Property
- C16847
- UMLS 2011AA Property
- C0449851
- NCI Thesaurus ObjectClass
- C15220
- UMLS 2011AA ObjectClass
- C0011900
Description
Section Iv - Treatment
Description
HormoneTherapyAdministeredInd-3
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
AdjuvantHormoneTherapyChangeInd-3
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus Property
- C25446
- UMLS 2011AA Property
- C0392747
- NCI Thesaurus ObjectClass-2
- C2140
- UMLS 2011AA ObjectClass-2
- C0001552
Description
NewAdjuvantHormoneTherapyAdministeredType
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C25586
- UMLS 2011AA ObjectClass
- C0205314
- NCI Thesaurus ObjectClass-2
- C15445
- UMLS 2011AA ObjectClass-2
- C0279025
- NCI Thesaurus ObjectClass-3
- C2140
- UMLS 2011AA ObjectClass-3
- C0001552
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
Description
NewAdjuvantHormoneTherapyAdministeredDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C25586
- UMLS 2011AA ObjectClass
- C0205314
- NCI Thesaurus ObjectClass-2
- C15445
- UMLS 2011AA ObjectClass-2
- C0279025
- NCI Thesaurus ObjectClass-3
- C2140
- UMLS 2011AA ObjectClass-3
- C0001552
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
AdjuvantHormonalTherapyAdministeredType
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass-2
- C2140
- UMLS 2011AA ObjectClass-2
- C0001552
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
AdjuvantHormoneTherapyBeginDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass-2
- C2140
- UMLS 2011AA ObjectClass-2
- C0001552
- NCI Thesaurus Property
- C25431
- UMLS 2011AA Property
- C0439659
- NCI Thesaurus Property-2
- C25275
- UMLS 2011AA Property-2
- C2745955
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ValueDomain-2
- C25431
- UMLS 2011AA ValueDomain-2
- C0439659
Description
HormoneTherapyContinueInd-3
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C53279
- UMLS 2011AA Property
- C0549178
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
Description
HormoneTherapyLastAdministeredDate
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus Property
- C25551
- UMLS 2011AA Property
- C1517741
- NCI Thesaurus Property-2
- C25382
- UMLS 2011AA Property-2
- C1521801
Description
OvarianAntiestrogenHormoneTherapyAdministeredInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass-2
- C15757
- UMLS 2011AA ObjectClass-2
- C0854638
- NCI Thesaurus ObjectClass-3
- C28047
- UMLS 2011AA ObjectClass-3
- C0205065
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
OvarianAntiestrogenHormoneTherapyAdministeredType
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass-2
- C15757
- UMLS 2011AA ObjectClass-2
- C0854638
- NCI Thesaurus ObjectClass-3
- C28047
- UMLS 2011AA ObjectClass-3
- C0205065
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
Description
HormoneTherapyLuteinizingHormone-releasingHormoneAgonistAdministrationInd-3
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus Property
- C25409
- UMLS 2011AA Property
- C1533734
- NCI Thesaurus Property-2
- C1910
- UMLS 2011AA Property-2
- C1518041
Description
Section Viii - Non-protocol Therapy Prior To Recurrence
Description
Non-ProtocolTherapyFirstRecurrenceInd-3
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus ObjectClass-2
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus Property
- C3352
- UMLS 2011AA Property
- C0034897
- NCI Thesaurus Property-2
- C25509
- UMLS 2011AA Property-2
- C1279901
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Footer Module
Description
Investigator Signature
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- NCI Thesaurus ObjectClass
- C17089
Description
Investigator Signature Date
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- UMLS CUI-2
- C0011008
- NCI Thesaurus ValueDomain-2
- C25367
- NCI Thesaurus ObjectClass
- C17089
Similar models
Instructions: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule). Submit original to the ECOG Coordinating Center; Keep a copy for your files.
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C1301943 (UMLS CUI-1)
C25454 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ObjectClass-2)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25601 (NCI Thesaurus Property-2)
C1518544 (UMLS 2011AA Property-2)
C25207 (NCI Thesaurus Property-3)
C0040223 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C3846084 (UMLS CUI-1)
C18003 (NCI Thesaurus ValueDomain)
C25688 (NCI Thesaurus ValueDomain-2)
C25717 (NCI Thesaurus Property)
C0805839 (UMLS CUI-1)
C25461 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C0007465 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C28554 (NCI Thesaurus Property)
C25251 (NCI Thesaurus ValueDomain-2)
C0439673 (UMLS 2011AA)
C0007465 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-2)
C28554 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property)
C2361257 (UMLS CUI-1)
C25651 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
C1512699 (UMLS 2011AA ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C0205314 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1527021 (UMLS 2011AA ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C0205314 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C0277556 (UMLS 2011AA ObjectClass)
C25321 (NCI Thesaurus Property)
C0443203 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C1522577 (UMLS CUI-1)
C16033 (NCI Thesaurus Property)
C0006826 (UMLS CUI-2)
C9305 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property-2)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C0006826 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C17998 (NCI Thesaurus Property-2)
C0439673 (UMLS 2011AA Property-2)
C16033 (NCI Thesaurus Property-3)
C1522577 (UMLS 2011AA Property-3)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25577 (NCI Thesaurus ValueDomain-2)
C1513491 (UMLS 2011AA ValueDomain-2)
C1527021 (UMLS 2011AA ValueDomain)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C38103 (NCI Thesaurus Property-2)
C0039985 (UMLS 2011AA Property-2)
C17204 (NCI Thesaurus Property-3)
C0040405 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C2911685 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C16847 (NCI Thesaurus Property)
C0024671 (UMLS 2011AA)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25651 (NCI Thesaurus ValueDomain-2)
C0700287 (UMLS 2011AA ValueDomain-2)
C19477 (NCI Thesaurus Property)
C1704254 (UMLS 2011AA Property)
C0205160 (UMLS 2011AA)
C1446409 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C20178 (NCI Thesaurus ObjectClass)
C0024671 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C3694716 (UMLS CUI-1)
C16033 (NCI Thesaurus Property)
C25365 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C17998 (NCI Thesaurus Property)
C0439673 (UMLS 2011AA Property)
C0027643 (UMLS CUI-1)
C25388 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C15220 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus-3)
C1298908 (UMLS 2011AA-4)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus-3)
C1705108 (UMLS 2011AA-4)
C0439673 (UMLS 2011AA)
C0277556 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus Property)
C1947913 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C25331 (NCI Thesaurus Property)
C12674 (NCI Thesaurus Property-2)
C0004454 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C25331 (NCI Thesaurus Property)
C12904 (NCI Thesaurus Property-2)
C0729594 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C25331 (NCI Thesaurus Property)
C63705 (NCI Thesaurus Property-2)
C0229743 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C25331 (NCI Thesaurus Property)
C32853 (NCI Thesaurus Property-2)
C0229755 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C25331 (NCI Thesaurus Property)
C25308 (NCI Thesaurus Property-2)
C0441989 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25331 (NCI Thesaurus Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C12903 (NCI Thesaurus Property-2)
C0229730 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C15220 (NCI Thesaurus ObjectClass)
C0011900 (UMLS 2011AA ObjectClass)
C0205210 (UMLS 2011AA)
C0019638 (UMLS 2011AA)
C16681 (NCI Thesaurus-3)
C0019638 (UMLS 2011AA-4)
C0205394 (UMLS 2011AA)
C2911685 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-2)
C16847 (NCI Thesaurus Property)
C0027627 (UMLS CUI-1)
C25321 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C15220 (NCI Thesaurus Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C0277556 (UMLS 2011AA ObjectClass)
C25321 (NCI Thesaurus Property)
C0443203 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0277556 (UMLS 2011AA ObjectClass)
C25321 (NCI Thesaurus Property)
C0443203 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C15220 (NCI Thesaurus ObjectClass)
C0011900 (UMLS 2011AA ObjectClass)
C1512699 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25446 (NCI Thesaurus Property)
C0392747 (UMLS 2011AA Property)
C2140 (NCI Thesaurus ObjectClass-2)
C0001552 (UMLS 2011AA ObjectClass-2)
C0205314 (UMLS 2011AA ObjectClass)
C15445 (NCI Thesaurus ObjectClass-2)
C0279025 (UMLS 2011AA ObjectClass-2)
C2140 (NCI Thesaurus ObjectClass-3)
C0001552 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0039286 (UMLS 2011AA)
C0290882 (UMLS 2011AA)
C0246421 (UMLS 2011AA)
C0060116 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C0205314 (UMLS 2011AA ObjectClass)
C15445 (NCI Thesaurus ObjectClass-2)
C0279025 (UMLS 2011AA ObjectClass-2)
C2140 (NCI Thesaurus ObjectClass-3)
C0001552 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C0001552 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0039286 (UMLS 2011AA)
C0290882 (UMLS 2011AA)
C0246421 (UMLS 2011AA)
C0060116 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C0001552 (UMLS 2011AA ObjectClass-2)
C25431 (NCI Thesaurus Property)
C0439659 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0439659 (UMLS 2011AA ValueDomain-2)
C1512699 (UMLS 2011AA ValueDomain)
C53279 (NCI Thesaurus Property)
C0549178 (UMLS 2011AA Property)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus Property)
C1517741 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C0279025 (UMLS 2011AA ObjectClass)
C15757 (NCI Thesaurus ObjectClass-2)
C0854638 (UMLS 2011AA ObjectClass-2)
C28047 (NCI Thesaurus ObjectClass-3)
C0205065 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0279025 (UMLS 2011AA ObjectClass)
C15757 (NCI Thesaurus ObjectClass-2)
C0854638 (UMLS 2011AA ObjectClass-2)
C28047 (NCI Thesaurus ObjectClass-3)
C0205065 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C1522449 (UMLS 2011AA)
C1512699 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C1910 (NCI Thesaurus Property-2)
C1518041 (UMLS 2011AA Property-2)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass)
C3352 (NCI Thesaurus Property)
C0034897 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)