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
Lien
Mots-clés
Versions (3)
- 27/08/2012 27/08/2012 -
- 09/01/2015 09/01/2015 - Martin Dugas
- 17/09/2021 17/09/2021 -
Téléchargé le
27 août 2012
DOI
Pour une demande vous connecter.
Licence
Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :
Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.
Groupe Item commentaires pour :
Item commentaires pour :
Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.
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.
Description
Gnrh Analogue
Description
HormoneTherapyGonadotropin-ReleasingHormoneAnalogAdministeredType
Type de données
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
Description
HormoneTherapyLuteinizingHormone-releasingHormoneAgonistAdministrationSpecify
Type de données
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
Description
AgentAdministrationType
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Metathesaurus ObjectClass
- CL111054
- NCI Thesaurus Property
- C25409
- UMLS 2011AA Property
- C1533734
Description
DateAgentAdministered
Type de données
text
Description
Administeredby(initials)
Type de données
text
Description
BatchNumber
Type de données
text
Description
ComplianceCode
Type de données
text
Description
Other,specify(compliancecode)
Type de données
text
Description
Reasonnottakencode
Type de données
text
Description
Adverseevent,specify
Type de données
text
Description
Other,specify(reasonnottaken)
Type de données
text
Description
Isthisthefinaltreatment?
Type de données
text
Description
Surgical Oophorectomy
Description
Dateofsurgicaloophorectomy
Type de données
text
Description
BilateralOophorectomyPerformedIBCSGInd-2
Type de données
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
Description
BilateralOophorectomyPerformedIBCSGSpecify
Type de données
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
Description
Thisoophorectomyis
Type de données
text
Description
OvaryRemovedIBCSGReason
Type de données
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
Description
Bilateral Ovarian Radiation Therapy
Description
Confirmation Of Biochemical Evidence Of Cessation Of Ovarian Function After Ovarian Radiotherapy Is Completed.
Description
Estradiolpmol/L
Type de données
text
Description
Institutionallowerlimitforpremenopausal
Type de données
text
Description
Institutionalupperlimitforpostmenopausal
Type de données
text
Description
Dateblooddrawnforthisestradiollevel
Type de données
text
Description
Thisradiationtherapyis
Type de données
text
Description
RTTreatmentIBCSGReason
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS 2011AA ValueDomain
- C0392360
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C15368
Description
RTTreatmentIBCSGSpecify
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C15368
Description
InvestigatorSignatureText
Type de données
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
Description
InvestigatorSignatureDate
Type de données
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.
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA Property)
C0805701 (UMLS 2011AA ValueDomain)
C0034897 (UMLS 2011AA)
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)
C0120107 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C0077275 (UMLS 2011AA)
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)
C0332307 (UMLS 2011AA ValueDomain)
CL111054 (NCI Metathesaurus ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C0442117 (UMLS 2011AA)
C0443315 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
C0392360 (UMLS 2011AA ValueDomain)
C12404 (NCI Thesaurus ObjectClass)
C0029939 (UMLS 2011AA ObjectClass)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)
C0205394 (UMLS 2011AA)
C0392360 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA)
C1521902 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)