ID
1135
Beschreibung
CALGB-40502 Adverse Event (AE) Form Paclitaxel, Paclitaxel Albumin-Stabilized Nanoparticle Formulation, or Ixabepilone With or Without Bevacizumab in Treating Patients With Stage IIIC or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=51FAEE67-09C6-06EB-E044-0003BA3F9857
Link
Stichworte
Versionen (4)
- 27.08.12 27.08.12 -
- 09.01.15 09.01.15 - Martin Dugas
- 09.01.15 09.01.15 - Martin Dugas
- 08.07.15 08.07.15 -
Hochgeladen am
27. August 2012
DOI
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00785291 Toxicity - CALGB-40502 Adverse Event (AE) Form - 2765532v1.0
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. If data are amended, circle amended items and check the "Yes" box. If submitting by mail, retain a copy for your records. If submitting by fax, use an original form for maximum clarity in transmission and fax to 919-416-4990. Use NCI CTCAE v3.x with MedDRA codes posted at http://www.calgb.org to grade each adverse event. Grade = -1 if category not evaluated. Grade = 0 if category evaluated but event not present. AE is defined as adverse event. TREATMENT ATTRIBUTION CODES: 1 = unrelated, 2 = unlikely, 3 = possible, 4 = probable, 5 = definite
Beschreibung
Unnamed2
Beschreibung
PatientInitialsName
Datentyp
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
Beschreibung
PatientMedicalRecordNumber
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25261
- UMLS 2011AA Property
- C0205476
- NCI Thesaurus Property
- C25198
- UMLS 2011AA Property
- C0034869
Beschreibung
CombinedInstitutionName
Datentyp
text
Alias
- NCI Thesaurus ObjectClass
- C25454
- UMLS 2011AA ObjectClass
- C0205195
- NCI Thesaurus ObjectClass
- C21541
- UMLS 2011AA ObjectClass
- C0018704
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ValueDomain
- C25191
- UMLS 2011AA ValueDomain
- C1547383
- NCI Thesaurus ValueDomain
- C21541
- UMLS 2011AA ValueDomain
- C0018704
Beschreibung
ParticipatingGroupName
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS 2011AA ValueDomain
- C1547383
- NCI Thesaurus ObjectClass
- C25608
- UMLS 2011AA ObjectClass
- C0679823
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschreibung
ProtocolParticipatingIdentifierNumber
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C25320
- UMLS 2011AA ObjectClass
- C1507394
- NCI Thesaurus Property
- C25608
- UMLS 2011AA Property
- C0679823
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschreibung
PatientParticipatingIdentifierNumber
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25608
- UMLS 2011AA Property
- C0679823
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschreibung
Unnamed3
Beschreibung
AdverseEventReportInd-3
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus Property
- C25375
- UMLS 2011AA Property
- C0684224
- NCI Thesaurus ObjectClass
- C17648
- UMLS 2011AA ObjectClass
- C0439064
Beschreibung
Expected Adverse Events
Beschreibung
CommonToxicityCriteriaAdverseEventTermType
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Thesaurus Property
- C45559
- UMLS 2011AA Property
- C1705313
Beschreibung
CommonToxicityCriteriaAdverseEventTermType
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Thesaurus Property
- C45559
- UMLS 2011AA Property
- C1705313
Beschreibung
CTCAdverseEventAttributionScale
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Thesaurus Property
- C25358
- UMLS 2011AA Property
- C0596130
Beschreibung
CTCAdverseEventAttributionScale
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Thesaurus Property
- C25358
- UMLS 2011AA Property
- C0596130
Beschreibung
CommonToxicityCriteriaAdverseEventShortNameType
Datentyp
text
Alias
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Metathesaurus ValueDomain
- C0332307
- NCI Thesaurus Property
- C25249
- UMLS 2011AA Property
- C1806781
Beschreibung
CTCAdverseEventSpecifiedTermType
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Thesaurus Property
- C38024
- UMLS 2011AA Property
- C0205369
- NCI Thesaurus Property
- C45559
- UMLS 2011AA Property
- C1705313
Beschreibung
MedDRACode
Datentyp
double
Alias
- NCI Thesaurus ValueDomain
- C25162
- UMLS 2011AA ValueDomain
- C0805701
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Metathesaurus ObjectClass
- CL104089
Beschreibung
MedDRACode
Datentyp
double
Alias
- NCI Thesaurus ValueDomain
- C25162
- UMLS 2011AA ValueDomain
- C0805701
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Metathesaurus ObjectClass
- CL104089
Beschreibung
CommonToxicityCriteriaAdverseEventGrade
Datentyp
double
Alias
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Thesaurus ValueDomain
- C18000
- UMLS 2011AA ValueDomain
- C0919553
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Beschreibung
CommonToxicityCriteriaAdverseEventGrade
Datentyp
double
Alias
- NCI Thesaurus ObjectClass
- C49704
- UMLS 2011AA ObjectClass
- C1516728
- NCI Thesaurus ValueDomain
- C18000
- UMLS 2011AA ValueDomain
- C0919553
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Beschreibung
ResponsiblePersonName
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS 2011AA ValueDomain
- C1547383
- NCI Thesaurus ObjectClass
- C25657
- UMLS 2011AA ObjectClass
- C1273518
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschreibung
FormCompleteDate
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C40988
- UMLS 2011AA ObjectClass
- C1516308
- NCI Thesaurus Property
- C25250
- UMLS 2011AA Property
- C0205197
- NCI Thesaurus ValueDomain
- C25367
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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. If data are amended, circle amended items and check the "Yes" box. If submitting by mail, retain a copy for your records. If submitting by fax, use an original form for maximum clarity in transmission and fax to 919-416-4990. Use NCI CTCAE v3.x with MedDRA codes posted at http://www.calgb.org to grade each adverse event. Grade = -1 if category not evaluated. Grade = 0 if category evaluated but event not present. AE is defined as adverse event. TREATMENT ATTRIBUTION CODES: 1 = unrelated, 2 = unlikely, 3 = possible, 4 = probable, 5 = definite
C0237753 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus ObjectClass)
C1516238 (UMLS 2011AA ObjectClass)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C25375 (NCI Thesaurus Property)
C0684224 (UMLS 2011AA Property)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C25375 (NCI Thesaurus Property)
C0684224 (UMLS 2011AA Property)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25198 (NCI Thesaurus Property)
C0034869 (UMLS 2011AA Property)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25375 (NCI Thesaurus Property)
C0684224 (UMLS 2011AA Property)
C17648 (NCI Thesaurus ObjectClass)
C0439064 (UMLS 2011AA ObjectClass)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0332307 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C45559 (NCI Thesaurus Property)
C1705313 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C45559 (NCI Thesaurus Property)
C1705313 (UMLS 2011AA Property)
C0349674 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C25358 (NCI Thesaurus Property)
C0596130 (UMLS 2011AA Property)
C0445356 (UMLS 2011AA)
C0349674 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C25358 (NCI Thesaurus Property)
C0596130 (UMLS 2011AA Property)
C0445356 (UMLS 2011AA)
C0600091 (UMLS 2011AA Property)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C0332307 (NCI Metathesaurus ValueDomain)
C25249 (NCI Thesaurus Property)
C1806781 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C38024 (NCI Thesaurus Property)
C0205369 (UMLS 2011AA Property)
C45559 (NCI Thesaurus Property)
C1705313 (UMLS 2011AA Property)
C0805701 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL104089 (NCI Metathesaurus ObjectClass)
C0805701 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL104089 (NCI Metathesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C1513302 (UMLS 2011AA)
C1513374 (UMLS 2011AA)
C1519275 (UMLS 2011AA)
C1705232 (UMLS 2011AA)
C1516728 (UMLS 2011AA ObjectClass)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C1513302 (UMLS 2011AA)
C1513374 (UMLS 2011AA)
C1519275 (UMLS 2011AA)
C1705232 (UMLS 2011AA)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)