ID

1138

Description

Ovarian Function Suppression Form (Form 24-OFS) 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=B70C65E9-F1BA-21F5-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70C65E9-F1BA-21F5-E034-0003BA12F5E7

Keywords

  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 9/17/21 9/17/21 -
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August 27, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00659373 Treatment - Ovarian Function Suppression Form (Form 24-OFS) - 2080631v3.0

OVARIAN FUNCTION SUPPRESSION FORM (Form 24-OFS) Instructions: This form is to be completed and submitted for patients randomized to Ovarian Function Suppression (OFS) and for patients who were not randomized to receive OFS but received it. Submit this form at each follow-up period (every three months in Year 1, every six months in Years 2-6) until the completion of OFS. (If patient receives surgical oophorectomy, submit this form only once. If patient receives bilateral ovarian radiation therapy, submit until ovarian function suppression is confirmed.) 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.

Ccrr Module For Ovarian Function Suppression Form-revised (form 24-ofs)
Description

Ccrr Module For Ovarian Function Suppression Form-revised (form 24-ofs)

Patient ID No.
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (f m fl sl)
Description

PatientInitialsName

Data type

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 (day)
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus Property
C25155
UMLS 2011AA Property
C0005615
Participating Center/Affiliate
Description

ParticipatingCenter/Affiliate

Data type

text

Center Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Did patient receive Ovarian Function Suppression (OFS) during this follow-up period
Description

DidpatientreceiveOvarianFunctionSuppression(OFS)duringthisfollow-upperiod?

Data type

text

If OFS will start later, reason
Description

IfOFSwillstartlater,reason

Data type

text

Adverse event, specify
Description

Adverseevent,specify

Data type

text

Other, specify (OFS later)
Description

Other,specify(OFSlater)

Data type

text

Adverse event, specify
Description

Adverseevent,specify

Data type

text

If stopped early or never started, reason (select one and sign & date at the bottom of this form - DataFax only page 1.)
Description

Ifstoppedearlyorneverstarted,reason

Data type

text

Medical decision, specify
Description

Medicaldecision,specify

Data type

text

Medical decision, specify
Description

Medicaldecision,specify

Data type

text

Other, specify
Description

Other,

Data type

text

Which method(s) of OFS did patient receive?
Description

Whichmethod(s)ofOFSdidpatientreceive?

Data type

text

Gnrh Analogue
Description

Gnrh Analogue

Agent Name
Description

HormoneTherapyGonadotropin-ReleasingHormoneAnalogAdministeredType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C15445
UMLS 2011AA ObjectClass
C0279025
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus Property
C2022
UMLS 2011AA Property
C1268900
Other, specify
Description

HormoneTherapyLuteinizingHormone-releasingHormoneAgonistAdministrationSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15445
UMLS 2011AA ObjectClass
C0279025
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus Property
C1910
UMLS 2011AA Property
C1518041
Route of Administration
Description

AgentAdministrationType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Metathesaurus ObjectClass
CL111054
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
Date Agent Administered
Description

DateAgentAdministered

Data type

text

Administered by (initials)
Description

Administeredby(initials)

Data type

text

Batch Number
Description

BatchNumber

Data type

text

Compliance Code
Description

ComplianceCode

Data type

text

Other, specify (compliance code)
Description

Other,specify(compliancecode)

Data type

text

Reason not taken code
Description

Reasonnottakencode

Data type

text

Adverse event, specify
Description

Adverseevent,specify

Data type

text

Other, specify (reason not taken)
Description

Other,specify(reasonnottaken)

Data type

text

Is this the final treatment
Description

Isthisthefinaltreatment?

Data type

text

Surgical Oophorectomy
Description

Surgical Oophorectomy

Date of surgical oophorectomy (day month year)
Description

Dateofsurgicaloophorectomy

Data type

text

Was the oophorectomy bilateral
Description

BilateralOophorectomyPerformedIBCSGInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C13332
UMLS 2011AA ObjectClass
C0238767
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15291
UMLS 2011AA ObjectClass
C0029936
Reason
Description

BilateralOophorectomyPerformedIBCSGSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C13332
UMLS 2011AA ObjectClass
C0238767
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15291
UMLS 2011AA ObjectClass
C0029936
This oophorectomy is (Report oophorectomy for reasons other than protocol-related ovarian function suppression on Forms 24-E and 24-GYN.)
Description

Thisoophorectomyis

Data type

text

Reason
Description

OvaryRemovedIBCSGReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C12404
UMLS 2011AA ObjectClass
C0029939
NCI Thesaurus Property
C25650
UMLS 2011AA Property
C0849355
Bilateral Ovarian Radiation Therapy
Description

Bilateral Ovarian Radiation Therapy

Radiation Therapy Start Date (day month year)
Description

RTBeginDate

Data type

date

Radiation Therapy End Date (day month year)
Description

RTEndDate

Data type

date

Total Dose of Radiation Therapy (cGy)
Description

RTTotalDose

Data type

double

Confirmation Of Biochemical Evidence Of Cessation Of Ovarian Function After Ovarian Radiotherapy Is Completed.
Description

Confirmation Of Biochemical Evidence Of Cessation Of Ovarian Function After Ovarian Radiotherapy Is Completed.

Estradiol pmol/L
Description

Estradiolpmol/L

Data type

text

Institutional lower limit for premenopausal (pmol/L)
Description

Institutionallowerlimitforpremenopausal

Data type

text

Institutional upper limit for postmenopausal (pmol/L)
Description

Institutionalupperlimitforpostmenopausal

Data type

text

Date blood drawn for this estradiol level (day month year)
Description

Dateblooddrawnforthisestradiollevel

Data type

text

This radiation therapy is
Description

Thisradiationtherapyis

Data type

text

Reason
Description

RTTreatmentIBCSGReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C15368
Other, specify
Description

RTTreatmentIBCSGSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C15368
Investigator Signature (Designee)
Description

InvestigatorSignatureText

Data type

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 (day month year)
Description

InvestigatorSignatureDate

Data type

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

Similar models

OVARIAN FUNCTION SUPPRESSION FORM (Form 24-OFS) Instructions: This form is to be completed and submitted for patients randomized to Ovarian Function Suppression (OFS) and for patients who were not randomized to receive OFS but received it. Submit this form at each follow-up period (every three months in Year 1, every six months in Years 2-6) until the completion of OFS. (If patient receives surgical oophorectomy, submit this form only once. If patient receives bilateral ovarian radiation therapy, submit until ovarian function suppression is confirmed.) 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.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Ovarian Function Suppression Form-revised (form 24-ofs)
PatientStudyID,CoordinatingGroup
Item
Patient ID No.
text
PatientInitialsName
Item
Patient Initials (f m fl sl)
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 (day)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Item
Did patient receive Ovarian Function Suppression (OFS) during this follow-up period
text
Code List
Did patient receive Ovarian Function Suppression (OFS) during this follow-up period
CL Item
No, Will Never Start. (No, will never start.)
CL Item
No, Will Start Later, Submit With Next Follow-up Form (No, will start later)
CL Item
Yes, Continuing (Yes, continuing)
CL Item
Yes, But Stopped Early. (Yes, but stopped early)
CL Item
Yes, Completed Per Protocol (Yes, completed per protocol)
Item
If OFS will start later, reason
text
Code List
If OFS will start later, reason
CL Item
Patient Refusal (Patient refusal)
CL Item
Adverse Event(s), Specify (Adverse event(s), specify)
CL Item
Medical Decision, Specify (Medical decision, specify)
CL Item
Error (Error)
C0743559 (NCI Metathesaurus)
CL Item
Other, Specify (Other, specify)
Adverseevent,specify
Item
Adverse event, specify
text
Other,specify(OFSlater)
Item
Other, specify (OFS later)
text
Adverseevent,specify
Item
Adverse event, specify
text
Item
If stopped early or never started, reason (select one and sign & date at the bottom of this form - DataFax only page 1.)
text
Code List
If stopped early or never started, reason (select one and sign & date at the bottom of this form - DataFax only page 1.)
CL Item
Patient Refusal (Patient refusal)
CL Item
Adverse Event(s), Specify (Adverse event(s), specify)
CL Item
Medical Decision, Specify (Medical decision, specify)
CL Item
Recurrence (Recurrence)
C3352 (NCI Thesaurus)
C0034897 (UMLS 2011AA)
CL Item
Death On Study (Death on study)
CL Item
Error (Error)
C0743559 (NCI Metathesaurus)
CL Item
Other, Specify (Other, specify)
CL Item
Gnrh Analogue Failed To Suppress Ovarian Function (GnRH analogue failed to suppress ovarian function)
Medicaldecision,specify
Item
Medical decision, specify
text
Medicaldecision,specify
Item
Medical decision, specify
text
Other,
Item
Other, specify
text
Item
Which method(s) of OFS did patient receive?
text
Code List
Which method(s) of OFS did patient receive?
CL Item
Gnrh Analogue (GnRH analogue)
CL Item
Surgical Oophorectomy (Surgical oophorectomy)
CL Item
Bilateral ovarian radiation therapy (Bilateral ovarian radiation therapy)
Item Group
Gnrh Analogue
Item
Agent Name
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C2022 (NCI Thesaurus Property)
C1268900 (UMLS 2011AA Property)
Code List
Agent Name
CL Item
Decapeptyl (Decapeptyl)
CL Item
Goserelin (Goserelin)
C1374 (NCI Thesaurus)
C0120107 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Trelstar Depot (Trelstar Depot)
CL Item
Triptorelin (Triptorelin)
C1267 (NCI Thesaurus)
C0077275 (UMLS 2011AA)
HormoneTherapyLuteinizingHormone-releasingHormoneAgonistAdministrationSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C1910 (NCI Thesaurus Property)
C1518041 (UMLS 2011AA Property)
Item
Route of Administration
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL111054 (NCI Metathesaurus ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
Code List
Route of Administration
CL Item
Intramuscular (Intramuscular)
C27974 (NCI Thesaurus)
C0442117 (UMLS 2011AA)
CL Item
Subcutaneous (Subcutaneous)
C13353 (NCI Thesaurus)
C0443315 (UMLS 2011AA)
DateAgentAdministered
Item
Date Agent Administered
text
Administeredby(initials)
Item
Administered by (initials)
text
BatchNumber
Item
Batch Number
text
Item
Compliance Code
text
Code List
Compliance Code
CL Item
Taken As Per Protocol (Taken as per protocol)
CL Item
Delayed For At Least One Month (Delayed for at least one month)
CL Item
Not Taken At All (Not taken at all)
CL Item
Other, Specify (Other, specify)
Other,specify(compliancecode)
Item
Other, specify (compliance code)
text
Item
Reason not taken code
text
Code List
Reason not taken code
CL Item
Patient Refusal (Patient refusal)
CL Item
Recurrence/relapse (Recurrence/relapse)
CL Item
Adverse Event, Specify (Adverse event, specify)
CL Item
Other, Specify (Other, specify)
Adverseevent,specify
Item
Adverse event, specify
text
Other,specify(reasonnottaken)
Item
Other, specify (reason not taken)
text
Item
Is this the final treatment
text
Code List
Is this the final treatment
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Surgical Oophorectomy
Dateofsurgicaloophorectomy
Item
Date of surgical oophorectomy (day month year)
text
Item
Was the oophorectomy bilateral
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C13332 (NCI Thesaurus ObjectClass)
C0238767 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15291 (NCI Thesaurus ObjectClass)
C0029936 (UMLS 2011AA ObjectClass)
Code List
Was the oophorectomy bilateral
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
BilateralOophorectomyPerformedIBCSGSpecify
Item
Reason
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C13332 (NCI Thesaurus ObjectClass)
C0238767 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15291 (NCI Thesaurus ObjectClass)
C0029936 (UMLS 2011AA ObjectClass)
Item
This oophorectomy is (Report oophorectomy for reasons other than protocol-related ovarian function suppression on Forms 24-E and 24-GYN.)
text
Code List
This oophorectomy is (Report oophorectomy for reasons other than protocol-related ovarian function suppression on Forms 24-E and 24-GYN.)
CL Item
Initial Attempt At Ovarian Function Suppression (Initial attempt at ovarian function suppression)
CL Item
Surgical Oophorectomy After Receiving Gnrh Analogue (Surgical oophorectomy after receiving GnRH analogue)
CL Item
Surgical Oophorectomy After Receiving Failed Ovarian Radiation (Surgical oophorectomy after receiving failed ovarian radiation)
Item
Reason
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C12404 (NCI Thesaurus ObjectClass)
C0029939 (UMLS 2011AA ObjectClass)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)
Code List
Reason
CL Item
Gnrh Failed (GnRH failed)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item Group
Bilateral Ovarian Radiation Therapy
RTBeginDate
Item
Radiation Therapy Start Date (day month year)
date
RTEndDate
Item
Radiation Therapy End Date (day month year)
date
RTTotalDose
Item
Total Dose of Radiation Therapy (cGy)
double
Item Group
Confirmation Of Biochemical Evidence Of Cessation Of Ovarian Function After Ovarian Radiotherapy Is Completed.
Estradiolpmol/L
Item
Estradiol pmol/L
text
Institutionallowerlimitforpremenopausal
Item
Institutional lower limit for premenopausal (pmol/L)
text
Institutionalupperlimitforpostmenopausal
Item
Institutional upper limit for postmenopausal (pmol/L)
text
Dateblooddrawnforthisestradiollevel
Item
Date blood drawn for this estradiol level (day month year)
text
Item
This radiation therapy is
text
Code List
This radiation therapy is
CL Item
Initial Attempt At Ovarian Function Suppression (Initial attempt at ovarian function suppression)
CL Item
Bilateral Ovarian Radiation Therapy After Receiving Gnrh Analogue (Bilateral ovarian radiation therapy after receiving GnRH analogue)
Item
Reason
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
Code List
Reason
CL Item
Gnrh Failed (GnRH failed)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
RTTreatmentIBCSGSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
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 (day month year)
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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