ID

11395

Description

Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA0178-CF14-0F96-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA0178-CF14-0F96-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

July 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up

English

No Instruction available.

1 forms  
  1. StudyEvent: Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
    1. No Instruction available.
SWOG clinical trial administrative data
Description

SWOG clinical trial administrative data

SWOG Patient No
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

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/Member
Description

MainMemberInstitution/Affiliate

Data type

text

Physician (Groups other than SWOG)
Description

TreatingPhysician

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass-2
C25705
UMLS 2011AA ObjectClass-2
C1522326
Group Name
Description

ParticipatingGroupName

Data type

text

Study No.
Description

StudyNo.

Data type

text

Pt. No
Description

Pt.ID

Data type

text

Vital Status
Description

Vital Status

Vital Status
Description

Patient'sVitalStatus

Data type

text

Date of last contact or death
Description

DeathDate/LastContactDate

Data type

date

Disease Follow-up Status
Description

Disease Follow-up Status

Has the patient been assessed for this cancer since submission of the last form?
Description

CancerFollow-upStatusInd

Data type

boolean

Date of assessment
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of First Relapse Or Progression
Description

Notice Of First Relapse Or Progression

Has the patient had a first relapse or progression of this cancer that has not been previously reported?
Description

ProgressionInd

Data type

boolean

Date of Relapse
Description

ProgressionDate

Data type

date

Site(s) of relapse
Description

Sites(progressionorrelapse)

Data type

text

Notice Of New Primary
Description

Notice Of New Primary

Has a new malignant neoplasm or myelodysplastic syndrome (MDS) been diagnosed since the last form?
Description

Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date of new primary
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Specify new primary site
Description

NewPrimarySite

Data type

text

Non-protocol Treatment
Description

Non-protocol Treatment

Has the patient received any (non-protocol) cancer treatment since submission of the last S0201 Adjuvant Melanoma Follow-up Form?
Description

Non-ProtocolTherapyInd

Data type

boolean

Surgery?
Description

Non-protocolSurgeryPerformedInd-3

Data type

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
Date (surgery)
Description

SurgeryDate

Data type

date

Specify (surgery
Description

Non-ProtocolSurgeryType

Data type

text

Systemic therapy?
Description

Non-ProtocolChemotherapyInd

Data type

boolean

Date (systemic therapy)
Description

ChemotherapyBeginDate

Data type

date

Specify agents, dose, schedule
Description

Non-ProtocolChemotherapyAdministeredSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass-2
C1518384
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Radiation Therapy?
Description

Non-ProtocolRTInd

Data type

boolean

Date (RT)
Description

RTBeginDate

Data type

date

Specify (RT)
Description

Non-ProtocolRTType

Data type

text

Other therapy?
Description

OtherTherapyInd

Data type

boolean

Specify (other therapy)
Description

OtherTherapyName

Data type

text

Ccrr Module For Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
Description

Ccrr Module For Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
SWOG clinical trial administrative data
SWOGPatientID
Item
SWOG Patient No
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/Member
text
TreatingPhysician
Item
Physician (Groups other than SWOG)
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
ParticipatingGroupName
Item
Group Name
text
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. No
text
Item Group
Vital Status
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death
date
Item Group
Disease Follow-up Status
CancerFollow-upStatusInd
Item
Has the patient been assessed for this cancer since submission of the last form?
boolean
CancerFollow-upStatusDate
Item
Date of assessment
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Notice Of First Relapse Or Progression
ProgressionInd
Item
Has the patient had a first relapse or progression of this cancer that has not been previously reported?
boolean
ProgressionDate
Item
Date of Relapse
date
Item
Site(s) of relapse
text
CL.4
Code List
Site(s) of relapse
CL Item
Local Recurrence (local-recurrence)
CL Item
In-transit Recurrence (in-transit recurrence)
CL Item
Regional Recurrence (regional recurrence)
CL Item
Distant Metastasis (distant metastasis)
C18206 (NCI Thesaurus)
C1269798 (UMLS 2011AA)
Item Group
Notice Of New Primary
Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?
Item
Has a new malignant neoplasm or myelodysplastic syndrome (MDS) been diagnosed since the last form?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
NewPrimaryCancerDate
Item
Date of new primary
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
Specify new primary site
text
Item Group
Non-protocol Treatment
Non-ProtocolTherapyInd
Item
Has the patient received any (non-protocol) cancer treatment since submission of the last S0201 Adjuvant Melanoma Follow-up Form?
boolean
Non-protocolSurgeryPerformedInd-3
Item
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)
SurgeryDate
Item
Date (surgery)
date
Non-ProtocolSurgeryType
Item
Specify (surgery
text
Non-ProtocolChemotherapyInd
Item
Systemic therapy?
boolean
ChemotherapyBeginDate
Item
Date (systemic therapy)
date
Non-ProtocolChemotherapyAdministeredSpecify
Item
Specify agents, dose, schedule
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Non-ProtocolRTInd
Item
Radiation Therapy?
boolean
RTBeginDate
Item
Date (RT)
date
Non-ProtocolRTType
Item
Specify (RT)
text
OtherTherapyInd
Item
Other therapy?
boolean
OtherTherapyName
Item
Specify (other therapy)
text
Item Group
Ccrr Module For Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
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