ID

11390

Beschrijving

Form 5 - On & Off Treatment Follow-Up Report NCT00049543 Gefitinib in Treating Patients With Non-Small Cell Lung Cancer That Has Been Surgically Removed Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0E01D72-7CAF-3016-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0E01D72-7CAF-3016-E034-080020C9C0E0

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 03-07-15 03-07-15 -
Geüploaded op

3 juli 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Form 5 - On & Off Treatment Follow-Up Report NCT00049543

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Form 5 - On & Off Treatment Follow-Up Report
    1. No Instruction available.
1. Patient Information
Beschrijving

1. Patient Information

Pt. Serial #
Beschrijving

PatientStudyID,CoordinatingGroup

Datatype

text

Hospital #
Beschrijving

PatientMedicalRecordNumber

Datatype

text

Pt. Initials
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Intergroup Patient Serial #
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Site #
Beschrijving

NCIInstitutionNumber

Datatype

text

Patient's Social Security # (USA only)
Beschrijving

PatientSocialSecurityNumber

Datatype

float

Institution
Beschrijving

InstitutionName

Datatype

text

Investigator
Beschrijving

RegisteredInvestigator

Datatype

text

2. Month Of Report
Beschrijving

2. Month Of Report

Month of report: (circle one)
Beschrijving

VisitReportMonthCount

Datatype

text

Alias
NCI Thesaurus Property
C29846
UMLS 2011AA Property
C0439231
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass-2
C25716
UMLS 2011AA ObjectClass-2
C0545082
Header
Beschrijving

Header

Datatype

text

3. Physical Exam
Beschrijving

3. Physical Exam

Date of Attendance
Beschrijving

CancerFollow-upStatusDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Weight (kg)
Beschrijving

PatientWeight

Datatype

float

Performance status (ECOG circle one see Appendix II of protocol)
Beschrijving

PerformanceStatus

Datatype

text

4. Disease Status
Beschrijving

4. Disease Status

4. DISEASE STATUS
Beschrijving

CancerFollow-upStatus,Recent

Datatype

text

5. Systemic Therapy Report
Beschrijving

5. Systemic Therapy Report

During the timeframe of this report, were full doses of Iressa/placebo taken daily by the patient?
Beschrijving

DoseModification(Change)

Datatype

text

give reason (If no, check _ all that apply)
Beschrijving

TherapyModificationReason

Datatype

text

dose modification due toxicity - please specify toxicity and grade
Beschrijving

dosemodificationduetoxicity-pleasespecifytoxicityandgrade

Datatype

text

temporary interruption for toxicity - please specify toxicity and grade
Beschrijving

temporaryinterruptionfortoxicity-pleasespecifytoxicityandgrade

Datatype

text

other: specify
Beschrijving

other:specify

Datatype

text

Will this patient continue to receive protocol therapy?
Beschrijving

OffTreatmentIndicator

Datatype

boolean

If this is the first On Treatment Follow-up, give date study medication was first taken
Beschrijving

FirstDoseStartDate,FirstCycle

Datatype

date

Ncic Ctg Use Only
Beschrijving

Ncic Ctg Use Only

Logged
Beschrijving

LoggedEntryInitials

Datatype

text

Entry date
Beschrijving

Entry date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0011008
Study Coord
Beschrijving

CoordinatorReviewInitials

Datatype

text

Coordinator Review Date
Beschrijving

Coordinator Review Date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0011008
Phy
Beschrijving

PhysicianReviewInitials

Datatype

text

Data Ent'd
Beschrijving

DataEntryInitials

Datatype

text

Verified
Beschrijving

DataVerificationInitials

Datatype

text

Header
Beschrijving

Header

6. Notice Of New Primary
Beschrijving

6. Notice Of New Primary

Have any other malignancies or myelodysplastic syndrome been diagnosed?
Beschrijving

NewPrimaryCancerInd

Datatype

boolean

date of diagnosis
Beschrijving

NewPrimaryCancerDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Site of new primary
Beschrijving

NewPrimarySite

Datatype

text

Describe (An Adverse Event Report must be sent to NCIC CTG within 15 working days that diagnosis is known to the investigator. See protocol section 11.0 for details.)
Beschrijving

NewPrimaryDetail

Datatype

text

Ncic Ctg Use
Beschrijving

Ncic Ctg Use

Malignancy Type
Beschrijving

NewPrimaryMalignancyType

Datatype

text

7. Hematology
Beschrijving

7. Hematology

Units (Note: please circle one)
Beschrijving

Lab,UnitsofMeasure

Datatype

text

Date
Beschrijving

Lab,Hematology,SampleCollectionDate

Datatype

date

Hemoglobin
Beschrijving

Lab,Hematology,Hemoglobin

Datatype

float

Platelets
Beschrijving

Lab,Hematology,Platelets

Datatype

float

WBC
Beschrijving

Lab,Hematology,WBC

Datatype

float

Neutrophils %
Beschrijving

Lab,Hematology,Neutrophils,CellPercentage

Datatype

float

Neutrophils x 109/L
Beschrijving

Lab,Hematology,NeutrophilCount

Datatype

float

Bands* x 109/L
Beschrijving

Bands*x109/L

Datatype

text

8. Biochemistry
Beschrijving

8. Biochemistry

Date
Beschrijving

SpecimenCollectionDate

Datatype

date

total bilirubin
Beschrijving

Lab,Hepatic,Bilirubin

Datatype

float

U/L
Beschrijving

Lab,UnitsofMeasure

Datatype

text

AST (SGOT)
Beschrijving

Lab,Hepatic,SGOT

Datatype

float

Alkaline Phosphatase
Beschrijving

Lab,Hepatic,AlkalinePhosphatase

Datatype

float

UNL
Beschrijving

UNL

Datatype

text

9. Treatment Given Since Last Report To Ncic Ctg
Beschrijving

9. Treatment Given Since Last Report To Ncic Ctg

Is the patient receiving any non-protocol cancer therapy not previously reported? (if yes, specify below)
Beschrijving

Non-ProtocolTherapyInd

Datatype

boolean

Non-Protocol Hormonal Therapy? (include medical and surgical)
Beschrijving

Non-ProtocolHormonalTherapyInd

Datatype

boolean

Non-Protocol Chemotherapy?
Beschrijving

Non-ProtocolChemotherapyInd

Datatype

boolean

Non-Protocol Immunotherapy?
Beschrijving

Non-ProtocolImmunotherapyInd

Datatype

boolean

Non-Protocol Biologic Response Modifier?
Beschrijving

Non-ProtocolBRMInd

Datatype

boolean

Non-Protocol High Dose Chemotherapy/ Autologous Stem Cell Transplant?
Beschrijving

Non-ProtocolHDC/ASCTInd

Datatype

boolean

Non-Protocol Radiation Therapy?
Beschrijving

Non-ProtocolRTInd

Datatype

boolean

Non-Protocol Surgery?
Beschrijving

Non-protocolSurgeryPerformedInd-3

Datatype

boolean

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
Other Non-Protocol Therapy?
Beschrijving

OtherTherapyInd

Datatype

boolean

(specify)
Beschrijving

OtherNon-ProtocolTherapyName

Datatype

text

First ever chemotherapy or EGFR inhibitor given: (specify)
Beschrijving

Non-ProtocolFirstChemotherapyAgentName

Datatype

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
Date started
Beschrijving

Non-ProtocolFirstChemotherapyBeginDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25431
UMLS 2011AA ValueDomain-2
C0439659
Second ever chemotherapy or EGFR inhibitor given: (specify)
Beschrijving

Non-ProtocolSecondChemotherapyAgentName

Datatype

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
Date started(2nd)
Beschrijving

Non-ProtocolSecondChemotherapyBeginDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ncic Ctg Use2
Beschrijving

Ncic Ctg Use2

1st line
Beschrijving

TypeofSecondLineChemotherapy

Datatype

text

2nd line
Beschrijving

Secondlinetherapy

Datatype

text

10. On Treatment Long Term Toxicity
Beschrijving

10. On Treatment Long Term Toxicity

NCIC CTG Use only
Beschrijving

NCICCTGUseonly

Datatype

text

Did the patient experience any toxicities during the timeframe of this report? (if yes, please complete form below)
Beschrijving

Didthepatientexperienceanytoxicitiesduringthetimeframeofthisreport?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Toxicity Term
Beschrijving

CTCAdverseEventTerm

Datatype

text

rash / acne (please circle)
Beschrijving

rash/acne

Datatype

text

CTC Adverse Event Term, Other
Beschrijving

CTCAdverseEventTerm,Other

Datatype

text

Category Code*
Beschrijving

CTCAdverseEventCategory

Datatype

text

NCIC CTG use only Tox Code
Beschrijving

NCICCTGuseonlyToxCode

Datatype

text

Worst Severity/Grade* (0=None NA=Not Assessed * Code/grade according to Common Toxicity Criteria, Version 2.0)
Beschrijving

CTCAdverseEventGrade

Datatype

text

Relation to Protocol Therapy
Beschrijving

CTCAdverseEventAttributionCode

Datatype

text

COMMENTS
Beschrijving

Comments

Datatype

text

11. Comments
Beschrijving

11. Comments

12. Have You Attached Copies Of
Beschrijving

12. Have You Attached Copies Of

12. HAVE YOU ATTACHED COPIES OF
Beschrijving

HAVEYOUATTACHEDCOPIESOF

Datatype

text

13. Investigator Signature
Beschrijving

13. Investigator Signature

Date
Beschrijving

InvestigatorSignature

Datatype

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Name of Clinical Research Associate
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Ccrr Module For Form 5 - On & Off Treatment Follow-up Report
Beschrijving

Ccrr Module For Form 5 - On & Off Treatment Follow-up Report

Other
Beschrijving

VisitReportMonthSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C29846
UMLS 2011AA Property
C0439231
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Thesaurus ObjectClass-2
C25716
UMLS 2011AA ObjectClass-2
C0545082
Person Completing Form, First Name
Beschrijving

PersonCompletingForm,FirstName

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
SGPT
Beschrijving

Lab,Hepatic,SGPT

Datatype

float

Lactate Dehydrogenase (LDH)
Beschrijving

Lab,Chemistry,LactateDehydrogenase

Datatype

float

Creatinine
Beschrijving

Lab,Renal,Creatinine

Datatype

float

BUN
Beschrijving

Lab,Renal,BUN

Datatype

float

Potassium (K)
Beschrijving

Lab,Electrolytes,Potassium

Datatype

float

Sodium (Na)
Beschrijving

Lab,Electrolytes,Sodium

Datatype

float

Chloride (Cl)
Beschrijving

Lab,Electrolytes,Chloride

Datatype

float

Calcium (Ca)
Beschrijving

Lab,Electrolytes,Calcium

Datatype

float

Albumin
Beschrijving

Lab,Chemistry,Albumin

Datatype

float

Imaging Site
Beschrijving

DiagnosticImagingAnatomicSite

Datatype

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus Property-2
C25421
UMLS 2011AA Property-2
C0002808
Method of Evaluation
Beschrijving

AssessmentType

Datatype

text

Date of Evaluation
Beschrijving

AssessmentDate

Datatype

date

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1 Formulieren
  1. StudyEvent: Form 5 - On & Off Treatment Follow-Up Report
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
1. Patient Information
PatientStudyID,CoordinatingGroup
Item
Pt. Serial #
text
PatientMedicalRecordNumber
Item
Hospital #
text
Patient Initials
Item
Pt. Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientStudyID,ParticipatingGroup
Item
Intergroup Patient Serial #
text
NCIInstitutionNumber
Item
Site #
text
PatientSocialSecurityNumber
Item
Patient's Social Security # (USA only)
float
InstitutionName
Item
Institution
text
RegisteredInvestigator
Item
Investigator
text
Item Group
2. Month Of Report
Item
Month of report: (circle one)
text
C29846 (NCI Thesaurus Property)
C0439231 (UMLS 2011AA Property)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25716 (NCI Thesaurus ObjectClass-2)
C0545082 (UMLS 2011AA ObjectClass-2)
CL.1
Code List
Month of report: (circle one)
CL Item
Other Month (Other)
CL Item
27 Months (27)
CL Item
1 (1)
CL Item
3 (3)
CL Item
6 (6)
CL Item
9 (9)
CL Item
12 (12)
CL Item
15 (15)
CL Item
18 (18)
CL Item
21 (21)
CL Item
24 (24)
CL Item
30 (30)
CL Item
36 (36)
CL Item
42 (42)
CL Item
48 (48)
CL Item
54 (54)
CL Item
60 (60)
Header
Item
Header
text
Item Group
3. Physical Exam
CancerFollow-upStatusDate
Item
Date of Attendance
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
PatientWeight
Item
Weight (kg)
float
Item
Performance status (ECOG circle one see Appendix II of protocol)
text
CL.2
Code List
Performance status (ECOG circle one see Appendix II of protocol)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
Item Group
4. Disease Status
Item
4. DISEASE STATUS
text
CL.3
Code List
4. DISEASE STATUS
CL Item
No Evidence Of Disease (Absent)
CL Item
Cancer Present (Present)
Item Group
5. Systemic Therapy Report
Item
During the timeframe of this report, were full doses of Iressa/placebo taken daily by the patient?
text
CL.4
Code List
During the timeframe of this report, were full doses of Iressa/placebo taken daily by the patient?
CL Item
(i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
(i.e, The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
Item
give reason (If no, check _ all that apply)
text
CL.5
Code List
give reason (If no, check _ all that apply)
CL Item
dose modification due toxicity (dose modification due toxicity)
CL Item
temporary interruption for toxicity (temporary interruption for toxicity)
CL Item
patient non compliant/forgot (patient non compliant/forgot)
CL Item
other: specify (other: specify)
CL Item
permanent cessation of protocol therapy (permanent cessation of protocol therapy)
dosemodificationduetoxicity-pleasespecifytoxicityandgrade
Item
dose modification due toxicity - please specify toxicity and grade
text
temporaryinterruptionfortoxicity-pleasespecifytoxicityandgrade
Item
temporary interruption for toxicity - please specify toxicity and grade
text
other:specify
Item
other: specify
text
OffTreatmentIndicator
Item
Will this patient continue to receive protocol therapy?
boolean
FirstDoseStartDate,FirstCycle
Item
If this is the first On Treatment Follow-up, give date study medication was first taken
date
Item Group
Ncic Ctg Use Only
LoggedEntryInitials
Item
Logged
text
LoggedEntryDate
Item
Entry date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS CUI-1)
CoordinatorReviewInitials
Item
Study Coord
text
CoordinatorReviewDate
Item
Coordinator Review Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS CUI-1)
PhysicianReviewInitials
Item
Phy
text
DataEntryInitials
Item
Data Ent'd
text
DataVerificationInitials
Item
Verified
text
Item Group
Header
Item Group
6. Notice Of New Primary
NewPrimaryCancerInd
Item
Have any other malignancies or myelodysplastic syndrome been diagnosed?
boolean
NewPrimaryCancerDate
Item
date of diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
Site of new primary
text
NewPrimaryDetail
Item
Describe (An Adverse Event Report must be sent to NCIC CTG within 15 working days that diagnosis is known to the investigator. See protocol section 11.0 for details.)
text
Item Group
Ncic Ctg Use
NewPrimaryMalignancyType
Item
Malignancy Type
text
Item Group
7. Hematology
Item
Units (Note: please circle one)
text
CL.9
Code List
Units (Note: please circle one)
CL Item
X10^9/l (10^9/L)
CL Item
S/i (SI Units)
CL Item
Imperial (US Imperial Units)
CL Item
1000/mm3 (1000/mm3)
CL Item
Ul (ul)
CL Item
U/l (U/L)
CL Item
Mg/dl (mg/dL)
CL Item
Umol/l (umol/L)
CL Item
Meq/l (mEq/L)
CL Item
Mmol/l (mmol/L)
CL Item
G/dl (g/dl)
CL Item
G/l (g/L)
Lab,Hematology,SampleCollectionDate
Item
Date
date
Lab,Hematology,Hemoglobin
Item
Hemoglobin
float
Lab,Hematology,Platelets
Item
Platelets
float
Lab,Hematology,WBC
Item
WBC
float
Lab,Hematology,Neutrophils,CellPercentage
Item
Neutrophils %
float
Lab,Hematology,NeutrophilCount
Item
Neutrophils x 109/L
float
Bands*x109/L
Item
Bands* x 109/L
text
Item Group
8. Biochemistry
SpecimenCollectionDate
Item
Date
date
Lab,Hepatic,Bilirubin
Item
total bilirubin
float
Item
U/L
text
CL.15
Code List
U/L
CL Item
U/l (U/L)
Lab,Hepatic,SGOT
Item
AST (SGOT)
float
Lab,Hepatic,AlkalinePhosphatase
Item
Alkaline Phosphatase
float
UNL
Item
UNL
text
Item Group
9. Treatment Given Since Last Report To Ncic Ctg
Non-ProtocolTherapyInd
Item
Is the patient receiving any non-protocol cancer therapy not previously reported? (if yes, specify below)
boolean
Non-ProtocolHormonalTherapyInd
Item
Non-Protocol Hormonal Therapy? (include medical and surgical)
boolean
Non-ProtocolChemotherapyInd
Item
Non-Protocol Chemotherapy?
boolean
Non-ProtocolImmunotherapyInd
Item
Non-Protocol Immunotherapy?
boolean
Non-ProtocolBRMInd
Item
Non-Protocol Biologic Response Modifier?
boolean
Non-ProtocolHDC/ASCTInd
Item
Non-Protocol High Dose Chemotherapy/ Autologous Stem Cell Transplant?
boolean
Non-ProtocolRTInd
Item
Non-Protocol Radiation Therapy?
boolean
Non-protocolSurgeryPerformedInd-3
Item
Non-Protocol Surgery?
boolean
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)
OtherTherapyInd
Item
Other Non-Protocol Therapy?
boolean
OtherNon-ProtocolTherapyName
Item
(specify)
text
Non-ProtocolFirstChemotherapyAgentName
Item
First ever chemotherapy or EGFR inhibitor given: (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)
Non-ProtocolFirstChemotherapyBeginDate
Item
Date started
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0439659 (UMLS 2011AA ValueDomain-2)
Non-ProtocolSecondChemotherapyAgentName
Item
Second ever chemotherapy or EGFR inhibitor given: (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)
Non-ProtocolSecondChemotherapyBeginDate
Item
Date started(2nd)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ncic Ctg Use2
TypeofSecondLineChemotherapy
Item
1st line
text
Secondlinetherapy
Item
2nd line
text
Item Group
10. On Treatment Long Term Toxicity
Item
NCIC CTG Use only
text
CL.25
Code List
NCIC CTG Use only
CL Item
Acute Toxicity Database (Acute toxicity database)
CL Item
Delayed Toxicity Database (Delayed toxicity database)
Didthepatientexperienceanytoxicitiesduringthetimeframeofthisreport?
Item
Did the patient experience any toxicities during the timeframe of this report? (if yes, please complete form below)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
Toxicity Term
text
CL.27
Code List
Toxicity Term
CL Item
diarrhea (diarrhea)
CL Item
Chest Pain (CHEST PAIN (NON-CARDIAC AND NON-PLEURITIC))
C38665 (NCI Thesaurus)
C0008031 (UMLS 2011AA)
CL Item
Infection Without Neutropenia (INFECTION (WITHOUT NEUTROPENIA))
CL Item
Fatigue (FATIGUE (LETHARGY, MALAISE, ASTHENIA))
C3036 (NCI Thesaurus)
C0015672 (UMLS 2011AA)
CL Item
Dyspnea (DYSPNEA (SHORTNESS OF BREATH))
C2998 (NCI Thesaurus)
C0013404 (UMLS 2011AA)
CL Item
Rash/desquamation (RASH/DESQUAMATION)
CL Item
Dry Skin (DRY SKIN)
C0151908 (NCI Metathesaurus)
CL Item
Anorexia (ANOREXIA)
C2875 (NCI Thesaurus)
C0003123 (UMLS 2011AA)
CL Item
Pruritus (PRURITUS)
C3344 (NCI Thesaurus)
C0033774 (UMLS 2011AA)
CL Item
Constipation (CONSTIPATION)
C37930 (NCI Thesaurus)
C0009806 (UMLS 2011AA)
CL Item
Diarrhea For Patients Without Colostomy (DIARRHEA (PATIENTS WITHOUT COLOSTOMY))
CL Item
Nausea (nausea)
C3258 (NCI Thesaurus)
C0027497 (UMLS 2011AA)
CL Item
Vomiting (vomiting)
C3442 (NCI Thesaurus)
C0042963 (UMLS 2011AA)
CL Item
fatigue (fatigue)
CL Item
uveitis/keratitis (uveitis/keratitis)
CL Item
rash / acne (rash / acne)
CL Item
Unnamed2 (Unnamed2)
Item
rash / acne (please circle)
text
CL.28
Code List
rash / acne (please circle)
CL Item
Rash (rash)
CL Item
Acne (acne)
CTCAdverseEventTerm,Other
Item
CTC Adverse Event Term, Other
text
Item
Category Code*
text
CL.29
Code List
Category Code*
CL Item
GI (GI)
CL Item
Gastrointestinal (Gastrointestinal)
C13359 (NCI Thesaurus)
C0521362 (UMLS 2011AA)
CL Item
Dermatology/skin (Dermatology/Skin)
CL Item
Infection (Infection)
C0021311 (NCI Metathesaurus)
CL Item
Pulmonary (Pulmonary)
C13304 (NCI Thesaurus)
C2709248 (UMLS 2011AA)
CL Item
Constitutional Symptoms (Constitutional Symptoms)
CL Item
Pain (Pain)
C3303 (NCI Thesaurus)
C0030193 (UMLS 2011AA)
CL Item
FL (FL)
CL Item
OC (OC)
CL Item
SK (SK)
Item
NCIC CTG use only Tox Code
text
CL.30
Code List
NCIC CTG use only Tox Code
CL Item
Dia (DIA)
CL Item
Nau (NAU)
CL Item
Vom (VOM)
CL Item
Let (LET)
CL Item
Ker (KER)
CL Item
Ras (RAS)
CTCAdverseEventGrade
Item
Worst Severity/Grade* (0=None NA=Not Assessed * Code/grade according to Common Toxicity Criteria, Version 2.0)
text
Item
Relation to Protocol Therapy
text
CL.31
Code List
Relation to Protocol Therapy
CL Item
Unrelated (1=unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (2=unlikely)
CL Item
Possibly (3=possible)
CL Item
Probably (4=probable)
CL Item
Definitely (5=definite)
Comments
Item
COMMENTS
text
Item Group
11. Comments
Item Group
12. Have You Attached Copies Of
Item
12. HAVE YOU ATTACHED COPIES OF
text
CL.32
Code List
12. HAVE YOU ATTACHED COPIES OF
CL Item
Supporting documentation (Supporting documentation)
Item Group
13. Investigator Signature
InvestigatorSignature
Item
Date
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Name of Clinical Research Associate
text
Item Group
Ccrr Module For Form 5 - On & Off Treatment Follow-up Report
VisitReportMonthSpecify
Item
Other
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C29846 (NCI Thesaurus Property)
C0439231 (UMLS 2011AA Property)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus ObjectClass-2)
C0545082 (UMLS 2011AA ObjectClass-2)
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Lab,Hepatic,SGPT
Item
SGPT
float
Lab,Chemistry,LactateDehydrogenase
Item
Lactate Dehydrogenase (LDH)
float
Lab,Renal,Creatinine
Item
Creatinine
float
Lab,Renal,BUN
Item
BUN
float
Lab,Electrolytes,Potassium
Item
Potassium (K)
float
Lab,Electrolytes,Sodium
Item
Sodium (Na)
float
Lab,Electrolytes,Chloride
Item
Chloride (Cl)
float
Lab,Electrolytes,Calcium
Item
Calcium (Ca)
float
Lab,Chemistry,Albumin
Item
Albumin
float
Item
Imaging Site
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C25421 (NCI Thesaurus Property-2)
C0002808 (UMLS 2011AA Property-2)
CL.33
Code List
Imaging Site
CL Item
Chest (Chest)
C25389 (NCI Thesaurus)
C0817096 (UMLS 2011AA)
Item
Method of Evaluation
text
CL.34
Code List
Method of Evaluation
CL Item
Chest X-ray (Chest X-Ray)
CL Item
Not Evaluated (Not evaluated)
CL Item
Mri (MRI (NMR))
CL Item
Ct Scan (CT Scan)
AssessmentDate
Item
Date of Evaluation
date
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