ID

11367

Description

SOUTHWEST ONCOLOGY GROUP NOTICE OF DEATH (S0303) NCT00070122 Combination Chemotherapy and Bevacizumab in Treating Patients With Locally Advanced, Metastatic, or Recurrent Colorectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BC722876-4198-4172-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BC722876-4198-4172-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

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.

Back to model comments
Itemgroup comments for :

Item comments for :

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

SOUTHWEST ONCOLOGY GROUP NOTICE OF DEATH (S0303) NCT00070122

English

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 forms  
Header
Description

Header

SWOG Patient ID
Description

Trial subject ID SWOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1519429
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
Most Recent SWOG Study No.
Description

MostRecentSWOGStudyNo.

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
Institution/Affiliate
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
Physician (Groups other than SWOG)
Description

Investigator Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2826892
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C17089
NCI Thesaurus ObjectClass-2
C25644
Group Name
Description

Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2347449
NCI Thesaurus ObjectClass
C25608
NCI Thesaurus ObjectClass-2
C17005
NCI Thesaurus Property
C25364
Study No.
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
Pt. 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
Date of death
Description

Date of death

Date of Death (month / day / year)
Description

DeathDocumentedDate

Data type

date

Causes Of Death
Description

Causes Of Death

Any cancer (select one)
Description

Anycancer

Data type

text

If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
Description

PersonCancerAssociatedDeathType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus Property-2
C9305
UMLS 2011AA Property-2
C0006826
NCI Thesaurus Property-3
C25281
UMLS 2011AA Property-3
C0332281
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Cancer of most recent SWOG study, specify cancer
Description

CancerofmostrecentSWOGstudy,specifycancer

Data type

text

Cancer of other SWOG study, specify cancer
Description

CancerofotherSWOGstudy,specifycancer

Data type

text

Other cancer, specify
Description

Othercancer,specify

Data type

text

Toxicity from disease related treatment (select one)
Description

Toxicityfromdiseaserelatedtreatment

Data type

text

If Primary Cause, Contributory or Possible, specify treatment and toxicity
Description

IfPrimaryCause,ContributoryorPossible,specifytreatmentandtoxicity

Data type

text

Non-cancer and non-treatment related causes (select one)
Description

Non-cancerandnon-treatmentrelatedcauses

Data type

text

If Primary Cause, Contributory or Possible, specify
Description

IfPrimaryCause,ContributoryorPossible,specify

Data type

text

Autopsy?
Description

AutopsyPerformedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25153
UMLS 2011AA ObjectClass
C0004398
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
Source of death information (select all that apply)
Description

DeathInformationSource

Data type

text

Other, specify
Description

PatientDeathSourceSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
Comments
Description

Comments

Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Ccrr Module For Southwest Oncology Group Notice Of Death (s0303)
Description

Ccrr Module For Southwest Oncology Group Notice Of Death (s0303)

Back to the top of the page

Similar models

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Trial subject ID SWOG
Item
SWOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
MostRecentSWOGStudyNo.
Item
Most Recent SWOG Study No.
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)
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)
Investigator Name
Item
Physician (Groups other than SWOG)
text
C25191 (NCI Thesaurus ValueDomain)
C2826892 (UMLS CUI-1)
C25364 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C25644 (NCI Thesaurus ObjectClass-2)
Participating Group
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Study 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
Pt. 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)
Item Group
Date of death
DeathDocumentedDate
Item
Date of Death (month / day / year)
date
Item Group
Causes Of Death
Item
Any cancer (select one)
text
CL.1
Code List
Any cancer (select one)
CL Item
No2005686 (No)
CL Item
Primary_cause2005687 (Primary Cause)
CL Item
Contributory2005688 (Contributory)
CL Item
Possible2005689 (Possible)
CL Item
Unknown2005690 (Unknown)
Item
If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C9305 (NCI Thesaurus Property-2)
C0006826 (UMLS 2011AA Property-2)
C25281 (NCI Thesaurus Property-3)
C0332281 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
CL Item
Cancer_of_most_recent_s2005692 (Cancer of most recent SWOG study, specify cancer)
CL Item
Cancer_of_oth_swog_stdy2005693 (Cancer of other SWOG study, specify cancer)
CL Item
Other_cancer_specify2005694 (Other cancer, specify)
CancerofmostrecentSWOGstudy,specifycancer
Item
Cancer of most recent SWOG study, specify cancer
text
CancerofotherSWOGstudy,specifycancer
Item
Cancer of other SWOG study, specify cancer
text
Othercancer,specify
Item
Other cancer, specify
text
Item
Toxicity from disease related treatment (select one)
text
CL.3
Code List
Toxicity from disease related treatment (select one)
CL Item
No2005697 (No)
CL Item
Primary_cause2005698 (Primary Cause)
CL Item
Contributory2005699 (Contributory)
CL Item
Possible2005700 (Possible)
CL Item
Unknown2005701 (Unknown)
IfPrimaryCause,ContributoryorPossible,specifytreatmentandtoxicity
Item
If Primary Cause, Contributory or Possible, specify treatment and toxicity
text
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No2005705 (No)
CL Item
Primary_cause2005706 (Primary Cause)
CL Item
Contributory2005707 (Contributory)
CL Item
Possible2005708 (Possible)
CL Item
Unknown2005709 (Unknown)
IfPrimaryCause,ContributoryorPossible,specify
Item
If Primary Cause, Contributory or Possible, specify
text
Item
Autopsy?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25153 (NCI Thesaurus ObjectClass)
C0004398 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
CL.5
Code List
Autopsy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Source of death information (select all that apply)
text
CL.6
Code List
Source of death information (select all that apply)
CL Item
Autopsy Was The Source Of Information On The Patient's Death (Autopsy report)
CL Item
Death Certificate Was The Source Of Information On The Patient's Death (Medical record / Death certificate)
CL Item
Clinical Evidence Was The Source Of Information On The Patient's Death (Physician)
CL Item
Relative or friend (Relative or friend)
CL Item
The Source Of Information On The Patient's Death Is Not On This List, Specify Other (Other, specify)
PatientDeathSourceSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item Group
Ccrr Module For Southwest Oncology Group Notice Of Death (s0303)
Back to the top of the page 

Contact

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

Fields marked with * are required.

Help

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