ID

11364

Description

NCT00057928 SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227) S0227 Comparison of Cisplatin Combined With Either Paclitaxel or Gemcitabine in Treating Patients With Recurrent, Persistent, or Metastatic Cervical Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C447B6-E4F0-3A7F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C447B6-E4F0-3A7F-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

July 3, 2015

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00057928 SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227)

English

No Instruction available.

1 forms  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227)
    1. No Instruction available.
Header
Description

Header

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Reporting Period Start Date (Date off protocol for the first follow-up form; last report period end date otherwise)
Description

IntervalReportFromDate

Data type

date

Institution / Affiliate
Description

InstitutionName

Data type

text

Physician (Groups other than SWOG)
Description

RegisteredInvestigator

Data type

text

Group Name
Description

ParticipatingGroupName

Data type

text

Study No.
Description

Particip.GroupProtocolNumber

Data type

float

Pt. ID
Description

PatientStudyID,ParticipatingGroup

Data type

text

Reporting Period End Date (Date of completion of the current form.)
Description

IntervalReportToDate

Data type

date

Vital Status
Description

Vital Status

Vital Status
Description

VitalStatus

Data type

text

Alias
NCI Thesaurus Property
C25717
UMLS 2011AA Property
C1148433
Date of last contact or death
Description

DeathDate/LastContactDate

Data type

date

Disease Follow Up Status
Description

Disease Follow Up Status

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Description

Hasthepatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?

Data type

boolean

Date of Last Clinical Assessment (If Yes)
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of First Relapse Or Progression
Description

Notice Of First Relapse Or Progression

Has the patient developed a first protocol defined relapse or progression that has not been previously reported
Description

Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?

Data type

boolean

Date of progression/relapse
Description

ProgressionDate,First

Data type

date

Site
Description

ProgressionSite

Data type

text

Notice Of New Primary
Description

Notice Of New Primary

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Description

NewPrimaryCancerInd

Data type

boolean

Date of Diagnosis (If Yes)
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site
Description

NewPrimarySite

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Non-protocol Treatment
Description

Non-protocol Treatment

Has the patient received any (non-protocol) cancer treatment in this reporting period
Description

ConcurrentNon-ProtocolTherapyInd

Data type

boolean

Non-Protocol Surgery (If Yes, complete the following)
Description

Non-protocolSurgeryPerformedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass-2
C1518384
Non-Protocol Chemotherapy (if yes, Treatment Start Date)
Description

Non-ProtocolChemotherapyInd

Data type

text

Non-Protocol Hormonal Therapy (if yes, Treatment Start Date)
Description

Non-ProtocolHormonalTherapyInd

Data type

text

Non-Protocol Immunotherapy (if yes, Treatment Start Date)
Description

Non-ProtocolImmunotherapyInd

Data type

text

Non-Protocol Radiation Therapy (if yes, Treatment Start Date)
Description

Non-ProtocolRTInd

Data type

text

Other Non-Protocol Therapy (if yes, Treatment Start Date)
Description

OtherNon-ProtocolTherapyInd

Data type

text

Yes, specify
Description

Non-ProtocolTherapyType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass-2
C2167
UMLS 2011AA ObjectClass-2
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Long Term Toxicity
Description

Long Term Toxicity

Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade >= 3) long term toxicity that has not been previously reported?
Description

LateAdverseEventInd

Data type

boolean

Neuropathy-motor
Description

Neuropathy-motor

Data type

boolean

Grade
Description

Grade

Data type

text

Neuropathy-sensory
Description

Neuropathy-sensory

Data type

boolean

Other (specify Toxicities and Grades)
Description

OtherInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
Comments
Description

Comments

Ccrr Module For Southwest Oncology Group S0227 Follow Up Form (s0227)
Description

Ccrr Module For Southwest Oncology Group S0227 Follow Up Form (s0227)

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No Instruction available.

1 forms
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
IntervalReportFromDate
Item
Reporting Period Start Date (Date off protocol for the first follow-up form; last report period end date otherwise)
date
InstitutionName
Item
Institution / Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
ParticipatingGroupName
Item
Group Name
text
Particip.GroupProtocolNumber
Item
Study No.
float
PatientStudyID,ParticipatingGroup
Item
Pt. ID
text
IntervalReportToDate
Item
Reporting Period End Date (Date of completion of the current form.)
date
Item Group
Vital Status
Item
Vital Status
text
C25717 (NCI Thesaurus Property)
C1148433 (UMLS 2011AA Property)
CL.1
Code List
Vital Status
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death
date
Item Group
Disease Follow Up Status
Hasthepatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
boolean
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment (If Yes)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Notice Of First Relapse Or Progression
Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?
Item
Has the patient developed a first protocol defined relapse or progression that has not been previously reported
boolean
ProgressionDate,First
Item
Date of progression/relapse
date
ProgressionSite
Item
Site
text
Item Group
Notice Of New Primary
NewPrimaryCancerInd
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
boolean
NewPrimaryCancerDate
Item
Date of Diagnosis (If Yes)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Non-protocol Treatment
ConcurrentNon-ProtocolTherapyInd
Item
Has the patient received any (non-protocol) cancer treatment in this reporting period
boolean
Item
Non-Protocol Surgery (If Yes, complete the following)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
CL.6
Code List
Non-Protocol Surgery (If Yes, complete the following)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Chemotherapy (if yes, Treatment Start Date)
text
CL.7
Code List
Non-Protocol Chemotherapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Hormonal Therapy (if yes, Treatment Start Date)
text
CL.8
Code List
Non-Protocol Hormonal Therapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Immunotherapy (if yes, Treatment Start Date)
text
CL.9
Code List
Non-Protocol Immunotherapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Radiation Therapy (if yes, Treatment Start Date)
text
CL.10
Code List
Non-Protocol Radiation Therapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Other Non-Protocol Therapy (if yes, Treatment Start Date)
text
CL.11
Code List
Other Non-Protocol Therapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolTherapyType
Item
Yes, specify
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass-2)
C1443775 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item Group
Long Term Toxicity
LateAdverseEventInd
Item
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade >= 3) long term toxicity that has not been previously reported?
boolean
Neuropathy-motor
Item
Neuropathy-motor
boolean
Grade
Item
Grade
text
Neuropathy-sensory
Item
Neuropathy-sensory
boolean
OtherInd-3
Item
Other (specify Toxicities and Grades)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
Item Group
Comments
Item Group
Ccrr Module For Southwest Oncology Group S0227 Follow Up Form (s0227)
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