ID

11389

Beskrivning

Southwest Oncology Group Lung Carcinoma Follow Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CDF62A-7230-112A-E034-080020C9C0E0

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CDF62A-7230-112A-E034-080020C9C0E0

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-07-03 2015-07-03 -
Uppladdad den

3 juli 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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Southwest Oncology Group Lung Carcinoma Follow Up Form

No Instruction available.

  1. StudyEvent: Southwest Oncology Group Lung Carcinoma Follow Up Form
    1. No Instruction available.
SWOG clinical trial administrative data
Beskrivning

SWOG clinical trial administrative data

SWOG Patient ID
Beskrivning

SWOGPatientID

Datatyp

text

SWOG Study No.
Beskrivning

SWOGStudyNo.

Datatyp

text

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Patient Initials (L, F M)
Beskrivning

Patient Initials

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191 (undefined)
UMLS CUI-1
C2986440 (Person Initials)
NCI Thesaurus ObjectClass
C16960 (undefined)
NCI Thesaurus Property
C25536 (undefined)
Institution/Affiliate
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

Physician (Groups other than SWOG)
Beskrivning

RegisteredInvestigator

Datatyp

text

Group Name
Beskrivning

GroupName

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191 (undefined)
UMLS 2011AA ValueDomain
C1547383 (Person Name)
SNOMED
734006007
NCI Thesaurus ObjectClass
C17005 (undefined)
UMLS 2011AA ObjectClass
C1257890 (Population Group)
SNOMED
389109008
LOINC
LA12078-4
NCI Thesaurus Property
C25364 (undefined)
UMLS 2011AA Property
C0600091 (Identifier)
SNOMED
118522005
LOINC
LP31795-5
Study No.
Beskrivning

StudyNo.

Datatyp

text

Pt. ID (Vital Status)
Beskrivning

Pt.ID

Datatyp

text

Lung Carcinoma Follow Up
Beskrivning

Lung Carcinoma Follow Up

Vital Status
Beskrivning

Patient'sVitalStatus

Datatyp

text

Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
Beskrivning

DeathDate/LastContactDate

Datatyp

date

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

CancerFollow-upStatusInd

Datatyp

boolean

Date of Last Clinical Assessment (Notice of First Relapse or Progression)
Beskrivning

CancerFollow-upStatusDate

Datatyp

date

Alias
NCI Thesaurus ObjectClass
C2991 (undefined)
UMLS 2011AA ObjectClass
C0012634 (Disease)
SNOMED
64572001
LOINC
LP21006-9
NCI Thesaurus Property
C25365 (undefined)
UMLS 2011AA Property
C0678257 (Description)
LOINC
LP6800-9
Has the patient developed a first progression (or relapse) that has not been previously reported?
Beskrivning

ProgressionInd

Datatyp

boolean

Date of Relapse or Progression (If yes, please submit the Lung Carcinoma First Sites of Progression or Relapse Form.)
Beskrivning

ProgressionDate

Datatyp

date

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If yes,)
Beskrivning

NewPrimaryCancerInd

Datatyp

boolean

Date of Diagnosis
Beskrivning

NewPrimaryCancerDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164 (undefined)
UMLS 2011AA ValueDomain
C0011008 (Date in time)
SNOMED
410671006
New Primary Site (Further Treatment)
Beskrivning

NewPrimarySite

Datatyp

text

Has the patient received further (non-protocol) treatment for this cancer? (If yes,)
Beskrivning

Non-ProtocolTherapyInd

Datatyp

boolean

Date of first non-protocol therapy
Beskrivning

Non-ProtocolTherapyDate,First

Datatyp

date

Specify regimen (Note: If multiple regimens were received, please specify only the first regimen received after going off protocol treatment.)
Beskrivning

Non-ProtocolTherapyType

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25590 (undefined)
UMLS 2011AA ObjectClass
C1518384 (Non-Protocol)
NCI Thesaurus ObjectClass-2
C2167 (undefined)
UMLS 2011AA ObjectClass-2
C1443775 (Epidermal growth factor receptor inhibitor (product))
SNOMED
409402009
NCI Thesaurus Property
C25382 (undefined)
UMLS 2011AA Property
C1521801 (Having administered)
Did the patient respond to this treatment?
Beskrivning

Didthepatientrespondtothistreatment?

Datatyp

boolean

Has the patient received prophylactic cranial irradiation (PCI)?
Beskrivning

prophylactic cranial irradiation

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148 (undefined)
UMLS CUI-1
C1514496 (Prophylactic Cranial Irradiation)
NCI Thesaurus ObjectClass
C16960 (undefined)
NCI Thesaurus Property
C25639 (undefined)
NCI Thesaurus Property-2
C15913 (undefined)
PCI Start Date (Long Term Toxicity)
Beskrivning

PCIStartDate

Datatyp

text

Toxicities and Grades
Beskrivning

CTCAdverseEventTerm

Datatyp

text

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?
Beskrivning

Hasthepatientexperienced(priortotreatmentforprogressionorrelapseorasecondprimary,andpriortonon-protocoltreatment)anysevere(grade>/=3)longtermtoxicitythathasnotbeenpreviouslyreported?

Datatyp

boolean

Comments
Beskrivning

Comments

Comments
Beskrivning

Comments

Datatyp

text

Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form
Beskrivning

Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form

Similar models

No Instruction available.

  1. StudyEvent: Southwest Oncology Group Lung Carcinoma Follow Up Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
SWOG clinical trial administrative data
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)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID (Vital Status)
text
Item Group
Lung Carcinoma Follow Up
Item
Vital Status
text
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
date
CancerFollow-upStatusInd
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 (Notice of First Relapse or Progression)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
ProgressionInd
Item
Has the patient developed a first progression (or relapse) that has not been previously reported?
boolean
ProgressionDate
Item
Date of Relapse or Progression (If yes, please submit the Lung Carcinoma First Sites of Progression or Relapse Form.)
date
NewPrimaryCancerInd
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If yes,)
boolean
NewPrimaryCancerDate
Item
Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site (Further Treatment)
text
Non-ProtocolTherapyInd
Item
Has the patient received further (non-protocol) treatment for this cancer? (If yes,)
boolean
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Non-ProtocolTherapyType
Item
Specify regimen (Note: If multiple regimens were received, please specify only the first regimen received after going off protocol treatment.)
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)
Didthepatientrespondtothistreatment?
Item
Did the patient respond to this treatment?
boolean
prophylactic cranial irradiation
Item
Has the patient received prophylactic cranial irradiation (PCI)?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1514496 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C15913 (NCI Thesaurus Property-2)
PCIStartDate
Item
PCI Start Date (Long Term Toxicity)
text
CTCAdverseEventTerm
Item
Toxicities and Grades
text
Hasthepatientexperienced(priortotreatmentforprogressionorrelapseorasecondprimary,andpriortonon-protocoltreatment)anysevere(grade>/=3)longtermtoxicitythathasnotbeenpreviouslyreported?
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
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form

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