ID

10796

Description

E1609 Source Document Tracking Coversheet NCT01274338 Ipilimumab or High-Dose Interferon Alfa-2b in Treating Patients With High-Risk Stage III or Stage IV Melanoma That Has Been Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9774BC47-50B5-931D-E040-BB89AD43322B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9774BC47-50B5-931D-E040-BB89AD43322B

Keywords

  1. 4/19/12 4/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 6/8/15 6/8/15 -
Uploaded on

June 8, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

E1609 Source Document Tracking Coversheet NCT01274338

ANLEITUNG: Füllen Sie dieses Formular aus und heften sich an jedes Quelldokument, um es zu ECOG zuversenden.

Unnamed2
Description

Unnamed2

Patienteninitialen (Nachname, Vorname)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
ECOG Protokoll-Nummer
Description

Protocol Number ECOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Patienten-ID
Description

Patient ID ECOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
Teilnehmende Gruppen Protokoll-Nummer
Description

Study Number Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Teilnehmenden Gruppen Patienten-ID
Description

Trial subject ID Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Institution / Einrichtung
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
DCI Vorname
Description

Generic drug form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C3242750
NCI Thesaurus Property
C19464
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus ObjectClass-2
C25452
Registrierungsschritt
Description

Registration Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1514821
NCI Thesaurus ObjectClass
C25646
UMLS CUI-2
C0237753
NCI Thesaurus Property
C16154
NCI Thesaurus ValueDomain-2
C16154
Behandlungs Berichtszeitraum ( Arm A und Arm B )
Description

Cycle number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C2045829
NCI Thesaurus Property
C25214
NCI Thesaurus Property-2
C25616
NCI Thesaurus ObjectClass
C15368
Behandlungs Berichtszeitraum
Description

Behandlungs Berichtszeitraum

Keine Behandlung
Description

Keine Behandlung

Kein-Behandlungs Berichtszeitraum (Wählen Sie eine)
Description

PersonOff-TreatmentTimePeriodType

Data type

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
Abschnitt II
Description

Abschnitt II

Dokumententype
Description

ProtocolDocumentSubmittedType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus ObjectClass-2
C19498
UMLS 2011AA ObjectClass-2
C1547673
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Datum der Berichtserstellung
Description

ReportCreatedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Thesaurus Property
C42620
UMLS 2011AA Property
C1706214

Similar models

ANLEITUNG: Füllen Sie dieses Formular aus und heften sich an jedes Quelldokument, um es zu ECOG zuversenden.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Patient Initials
Item
Patienteninitialen (Nachname, Vorname)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Protocol Number ECOG
Item
ECOG Protokoll-Nummer
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Patient ID ECOG
Item
ECOG Patienten-ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Study Number Participating Group
Item
Teilnehmende Gruppen Protokoll-Nummer
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Teilnehmenden Gruppen Patienten-ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Institution Name
Item
Institution / Einrichtung
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Generic drug form
Item
DCI Vorname
text
C25191 (NCI Thesaurus ValueDomain)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
Registration Number
Item
Registrierungsschritt
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Item
Behandlungs Berichtszeitraum ( Arm A und Arm B )
text
C25284 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
Code List
Behandlungs Berichtszeitraum ( Arm A und Arm B )
CL Item
Woche 5 (Week 5)
CL Item
Woche 9 (Week 9)
CL Item
Woche 13 (Week 13)
CL Item
Woche 19 (Week 19)
CL Item
Woche 25 (Week 25)
CL Item
Woche 31 (Week 31)
CL Item
Woche 37 (Week 37)
CL Item
Woche 43 (Week 43)
CL Item
Woche 49 (Week 49)
Item Group
Behandlungs Berichtszeitraum
Item Group
Keine Behandlung
Item
Kein-Behandlungs Berichtszeitraum (Wählen Sie eine)
text
C25190 (NCI Thesaurus ObjectClass)
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)
Code List
Kein-Behandlungs Berichtszeitraum (Wählen Sie eine)
CL Item
3 Monate (3 Months Post Registration)
CL Item
6 Monate (6 Months Post Registration)
CL Item
9 Monate (9 Months Post Registration)
CL Item
12 Monate (12 Months Post Registration)
CL Item
15 Monate (15 Months Post Registration)
CL Item
18 Monate (18 Months Post Registration)
CL Item
21 Monate nach der Registrierung (21 Months Post Registration)
CL Item
2 Jahre (24 Months Post Registration)
CL Item
30 Monate (30 Months Post Registration)
CL Item
3 Jahre (36 Months Post Registration)
CL Item
42 Monate (42 Months Post Registration)
CL Item
4 Jahre (48 Months Post Registration)
CL Item
54 Monate (54 Months Post Registration)
CL Item
5 Jahre (60 Months Post Registration)
CL Item
6 Jahre (72 Months Post Registration)
CL Item
84 Monate nach der Registrierunug (84 Months Post Registration)
CL Item
8 Jahre (96 months post registration)
CL Item
9 Jahre (108 months post registration)
CL Item
10 Jahre (120 months post registration)
CL Item
11 Jahre nach der Registrierunug (132 Months Post Registration)
CL Item
12 Jahre nach der Registrierunug (144 Months Post Registration)
CL Item
13 Jahre nach der Registrierunug (156 Months Post Registration)
CL Item
14 Jahre nach der Registrierunug (168 Months Post Registration)
CL Item
15 Jahre nach der Registrierunug (180 Months Post Registration)
CL Item
16 Jahre nach der Registrierunug (192 Months Post Registration)
CL Item
17 Jahre nach der Registrierunug (204 Months Post Registration)
CL Item
18 Jahre nach der Registrierunug (216 Months Post Registration)
CL Item
19 Jahre nach der Registrierunug (228 Months Post Registration)
CL Item
20 Jahre nach der Registrierunug (240 Months Post Registration)
Item Group
Abschnitt II
Item
Dokumententype
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C19498 (NCI Thesaurus ObjectClass-2)
C1547673 (UMLS 2011AA ObjectClass-2)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
Code List
Dokumententype
CL Item
Pathologie-Bericht (Pathology Report)
C28277 (NCI Thesaurus)
C0807321 (UMLS 2011AA)
CL Item
OP-Bericht (Surgical Report)
CL Item
Patienten Interferon Tagebuch (Patient Interferon Diary)
CL Item
BRAF-Mutation (BRAF mutation)
ReportCreatedDate
Item
Datum der Berichtserstellung
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C42620 (NCI Thesaurus Property)
C1706214 (UMLS 2011AA Property)

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

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