ID

1091

Beschrijving

Bilateral Breast Radiotherapy Form (Form 24-BR) 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=0162063B-84EB-2286-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0162063B-84EB-2286-E044-0003BA3F9857

Trefwoorden

Versies (2)
  1. 27-08-12 27-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
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27 augustus 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Bilateral Breast Radiotherapy Form (Form 24-BR) - 2411259v1.0

Engels

BREAST RADIOTHERAPY FORM (Form 24-R) Instructions: Submit this form upon completion of radiotherapy or if radiotherapy was planned and not given. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 Formulieren  
Ccrr Module For Breast Radiotherapy Form (form 24-r)
Beschrijving

Ccrr Module For Breast Radiotherapy Form (form 24-r)

Patient ID No. (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Initials (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

PatientInitialsName

Datatype

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 (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

PatientBirthDate

Datatype

date

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

ParticipatingCenter/Affiliate

Datatype

text

Center Code
Beschrijving

ParticipatingGroupCode

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
This form is being completed for
Beschrijving

BreastSideAssessmentSite

Datatype

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus Property
C25306
UMLS 2011AA Property
C0441987
Did the patient receive intraoperative radiotherapy (IORT)? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Didthepatientreceiveintraoperativeradiotherapy(IORT)?

Datatype

text

Did patient start adjuvant postoperative radiotherapy? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Didpatientstartadjuvantpostoperativeradiotherapy?

Datatype

text

Date postoperative radiotherapy started (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Datepostoperativeradiotherapystarted

Datatype

text

Date postoperative radiotherapy ended (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Datepostoperativeradiotherapyended

Datatype

text

Total postoperative dose given without boost (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Totalpostoperativedosegivenwithoutboost

Datatype

text

Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

RTSite

Datatype

text

Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

RTSite,Other

Datatype

text

Was postoperative radiotherapy boost given? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Waspostoperativeradiotherapyboostgiven?

Datatype

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Total Dose to Boost Field(s) (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

BrachytherapyTotalDose,Boost

Datatype

double

For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Forthosepatientswhodidnotstartadjuvantradiotherapy,pleasegivereason

Datatype

text

Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Beschrijving

Other,

Datatype

text

Investigator Signature (/Designee)
Beschrijving

InvestigatorSignatureText

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beschrijving

InvestigatorSignatureDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
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Similar models

BREAST RADIOTHERAPY FORM (Form 24-R) Instructions: Submit this form upon completion of radiotherapy or if radiotherapy was planned and not given. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Ccrr Module For Breast Radiotherapy Form (form 24-r)
PatientStudyID,CoordinatingGroup
Item
Patient ID No. (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
PatientInitialsName
Item
Patient Initials (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
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 (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Item
This form is being completed for
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25306 (NCI Thesaurus Property)
C0441987 (UMLS 2011AA Property)
CL.1
Code List
This form is being completed for
CL Item
Left Breast/side (Left breast/side)
CL Item
Right Breast/side (Right breast/side)
Item
Did the patient receive intraoperative radiotherapy (IORT)? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.2
Code List
Did the patient receive intraoperative radiotherapy (IORT)? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Did patient start adjuvant postoperative radiotherapy? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.3
Code List
Did patient start adjuvant postoperative radiotherapy? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Datepostoperativeradiotherapystarted
Item
Date postoperative radiotherapy started (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Datepostoperativeradiotherapyended
Item
Date postoperative radiotherapy ended (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Totalpostoperativedosegivenwithoutboost
Item
Total postoperative dose given without boost (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Item
Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.4
Code List
Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
Breast (Breast)
CL Item
Supraclavicular lymph nodes (Supraclavicular lymph nodes)
CL Item
Internal mammary lymph nodes (Internal mammary lymph nodes)
CL Item
Chest wall (Chest wall)
CL Item
Axilla (Axilla)
CL Item
Other, please specify (Other, please specify)
RTSite,Other
Item
Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Item
Was postoperative radiotherapy boost given? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.5
Code List
Was postoperative radiotherapy boost given? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
BrachytherapyTotalDose,Boost
Item
Total Dose to Boost Field(s) (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
double
Item
For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.6
Code List
For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
Patient Refused (Patient refused)
CL Item
Initially Planned, But Physician Later Advised Against (Initially planned, but physician later advised against)
CL Item
Early Recurrence (Early recurrence)
CL Item
Early Death (Early death)
CL Item
Other, Please Specify (Other, please specify)
Other,
Item
Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
InvestigatorSignatureText
Item
Investigator Signature (/Designee)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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