ID

11414

Beschrijving

S0205 Notice of Death NCT00075686 S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11CBC94-4007-1D74-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11CBC94-4007-1D74-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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S0205 Notice of Death NCT00075686

Engels

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulieren  
Header
Beschrijving

Header

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

Most Recent SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Patient Initials (L, F M)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Institution
Beschrijving

InstitutionName

Datatype

text

Affiliate
Beschrijving

AffiliateName

Datatype

text

Physician (Groups other than SWOG)
Beschrijving

RegisteredInvestigator

Datatype

text

Group Name
Beschrijving

GroupName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study No.
Beschrijving

StudyNo.

Datatype

text

Pt. ID
Beschrijving

Pt.ID

Datatype

text

Date of death
Beschrijving

Date of death

Date of Death (month / day / year)
Beschrijving

DeathDate/LastContactDate

Datatype

date

Causes Of Death
Beschrijving

Causes Of Death

Non-cancer and non-treatment related causes (select one)
Beschrijving

DeathReason

Datatype

text

Non-cancer and non-treatment related causes (select one)
Beschrijving

DeathReason

Datatype

text

Non-cancer and non-treatment related causes (select one)
Beschrijving

DeathReason

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

Autopsy done?
Beschrijving

AutopsyInd

Datatype

text

Death information obtained from (select all that apply)
Beschrijving

DeathInformationSource

Datatype

text

Other, specify
Beschrijving

PatientDeathSourceSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
Notes
Beschrijving

Notes

Notes
Beschrijving

Comments

Datatype

text

Ccrr Module For S0205 Notice Of Death
Beschrijving

Ccrr Module For S0205 Notice Of Death

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Similar models

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
Most Recent SWOG Study No.
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)
InstitutionName
Item
Institution
text
AffiliateName
Item
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
text
Item Group
Date of death
DeathDate/LastContactDate
Item
Date of Death (month / day / year)
date
Item Group
Causes Of Death
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
Item
Autopsy done?
text
CL.5
Code List
Autopsy done?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Death information obtained from (select all that apply)
text
CL.6
Code List
Death information obtained from (select all that apply)
CL Item
Autopsy Was The Source Of Information On The Patient's Death (Autopsy report)
CL Item
Death Certificate Was The Source Of Information On The Patient's Death (Medical record / Death certificate)
CL Item
Physician (Physician)
CL Item
Relative or friend (Relative or friend)
CL Item
The Source Of Information On The Patient's Death Is Not On This List, Specify Other (Other, specify)
PatientDeathSourceSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
Item Group
Notes
Comments
Item
Notes
text
Item Group
Ccrr Module For S0205 Notice Of Death
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