ID

10948

Descripción

E3201 Second Primary Form NCT00068692 Comparison of Adjuvant Chemotherapy Regimens in Treating Patients With Stage II or Stage III Rectal Cancer Who Are Receiving Radiation Therapy and Fluorouracil Before or After Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B5523D6D-210C-6DCB-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B5523D6D-210C-6DCB-E034-0003BA12F5E7

Palabras clave

Versiones (3)
  1. 27/8/12 27/8/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 16/6/15 16/6/15 -
Subido en

16 de junio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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E3201 Second Primary Form NCT00068692

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: E3201 Second Primary Form
    1. No Instruction available.
Header
Descripción

Header

ECOG Protocol Number (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Descripción

Protocol Number ECOG

Tipo de datos

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 Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Descripción

Patient ID ECOG

Tipo de datos

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
DCI Name
Descripción

Generic drug form

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C3242750
NCI Thesaurus Property
C19464
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus ObjectClass-2
C25452
Registration Step
Descripción

Registration Number

Tipo de datos

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
Time period
Descripción

TimePeriod

Tipo de datos

text

Patient Initials
Descripción

Patient Initials

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Participating Group Protocol No.
Descripción

Study Number Participating Group

Tipo de datos

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
Participating Group Patient ID
Descripción

Trial subject ID Participating Group

Tipo de datos

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/Affiliate
Descripción

Institution Name

Tipo de datos

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
Are data amended? (If yes, please circle amended items in red)
Descripción

Data amended

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Second primary cancer assessment
Descripción

Second primary cancer assessment

Date of Diagnosis of Second Primary Cancer
Descripción

Second Primary Tumor Date

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C3262
UMLS CUI-1
C0751623
NCI Thesaurus ObjectClass-2
C25251
UMLS CUI-2
C0011008
NCI Thesaurus ObjectClass-3
C25666
NCI Thesaurus Property
C15220
NCI Thesaurus ValueDomain
C25164
Site of Second Primary Cancer
Descripción

SecondPrimaryMalignantNeoplasmAnatomicSiteText

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus ObjectClass-3
C25666
UMLS 2011AA ObjectClass-3
C0205436
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25421
UMLS 2011AA Property-2
C0002808
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Include information on histologic subtype(s).
Descripción

Includeinformationonhistologicsubtype(s).

Tipo de datos

text

Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols:
Descripción

BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols

Tipo de datos

text

Briefly describe treatment planned or given for the diagnosis of this second primary:
Descripción

Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:

Tipo de datos

text

Comments
Descripción

Comments

Comments
Descripción

Research Comments

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Investigator Signature
Descripción

InvestigatorSignature

Tipo de datos

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Investigator Signature Date
Descripción

Investigator Signature Date

Tipo de datos

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
Ccrr Module For E3201 Second Primary Form
Descripción

Ccrr Module For E3201 Second Primary Form

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No Instruction available.

1 formularios
  1. StudyEvent: E3201 Second Primary Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header
Protocol Number ECOG
Item
ECOG Protocol Number (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
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 Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
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)
Generic drug form
Item
DCI Name
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
Registration Step
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
Time period
text
CL.1
Code List
Time period
CL Item
Second Primary (Second Primary)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Protocol No.
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
Participating Group Patient 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/Affiliate
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)
Data amended
Item
Are data amended? (If yes, please circle amended items in red)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Second primary cancer assessment
Second Primary Tumor Date
Item
Date of Diagnosis of Second Primary Cancer
date
C3262 (NCI Thesaurus ObjectClass)
C0751623 (UMLS CUI-1)
C25251 (NCI Thesaurus ObjectClass-2)
C0011008 (UMLS CUI-2)
C25666 (NCI Thesaurus ObjectClass-3)
C15220 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
SecondPrimaryMalignantNeoplasmAnatomicSiteText
Item
Site of Second Primary Cancer
text
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C0205436 (UMLS 2011AA ObjectClass-3)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property-2)
C0002808 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Includeinformationonhistologicsubtype(s).
Item
Include information on histologic subtype(s).
text
BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols
Item
Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols:
text
Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:
Item
Briefly describe treatment planned or given for the diagnosis of this second primary:
text
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
Investigator Signature Date
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
Item Group
Ccrr Module For E3201 Second Primary Form
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