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ID

11438

Description

ACNS0122 Death Worksheet NCT00047320 Neoadjuvant Chemotherapy With or Without Second-Look Surgery Followed by Radiation Therapy With or Without Peripheral Stem Cell Transplantation in Treating Patients With Intracranial Germ Cell Tumors Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD40BB6B-6EA3-0C19-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD40BB6B-6EA3-0C19-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/5/15 7/5/15 -
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July 5, 2015

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Creative Commons BY-NC 3.0 Legacy
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    ACNS0122 Death Worksheet NCT00047320

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: ACNS0122 Death Worksheet
      1. No Instruction available.
    Header
    Description

    Header

    Institution Name
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    COG Study No
    Description

    Protocol ID COG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516477
    NCI Thesaurus Property
    C25364
    COG Study No
    Description

    Protocol ID COG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516477
    NCI Thesaurus Property
    C25364
    COG Patient ID
    Description

    PatientCOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C39353
    UMLS 2011AA Property-2
    C1516477
    Patient Initials
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Today's date
    Description

    Form Completion Date

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-1
    C1549507
    NCI Thesaurus Property
    C25250
    NCI Thesaurus Property-2
    C25604
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Date worksheet entered into RDE
    Description

    DataEnteredDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C37949
    UMLS 2011AA Property
    C1521975
    Death Assessment
    Description

    Death Assessment

    Date of Death
    Description

    Date last contact

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0805839
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C25461
    Contributing Cause of Death
    Description

    PatientDeathReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C28554
    UMLS 2011AA Property
    C0011065
    NCI Thesaurus ValueDomain-2
    C28554
    UMLS 2011AA ValueDomain-2
    C0011065
    Primary cause of Death
    Description

    PatientDeathPrimaryReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C28554
    UMLS 2011AA Property
    C0011065
    NCI Thesaurus ValueDomain-2
    C28554
    UMLS 2011AA ValueDomain-2
    C0011065
    please specify [primary cause of death] (If 'Other',)
    Description

    Cause of Death, specify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0007465
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1521902
    NCI Thesaurus Property
    C28554
    please specify [primary cause of death] (If 'Other',)
    Description

    Cause of Death, specify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0007465
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1521902
    NCI Thesaurus Property
    C28554
    Autopsy?
    Description

    AutopsyPerformedInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C25153
    UMLS 2011AA ObjectClass
    C0004398
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    How were the side effects of protocol therapy related to the patient's death?
    Description

    DeathClinicalTrialProtocolAttributionDeathAttributionType

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C28554
    UMLS 2011AA ObjectClass
    C0011065
    NCI Thesaurus Property
    C25320
    UMLS 2011AA Property
    C1507394
    NCI Thesaurus Property-2
    C25358
    UMLS 2011AA Property-2
    C0596130
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ValueDomain-2
    C28554
    UMLS 2011AA ValueDomain-2
    C0011065
    Comments
    Description

    Comments

    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Ccrr Module For Acns0122 Death Worksheet
    Description

    Ccrr Module For Acns0122 Death Worksheet

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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: ACNS0122 Death Worksheet
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Institution Name
    Item
    Institution Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Protocol ID COG
    Item
    COG Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516477 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Protocol ID COG
    Item
    COG Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516477 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    PatientCOGIdentifierNumber
    Item
    COG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C39353 (NCI Thesaurus Property-2)
    C1516477 (UMLS 2011AA Property-2)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Form Completion Date
    Item
    Today's date
    date
    C19464 (NCI Thesaurus ObjectClass)
    C1549507 (UMLS CUI-1)
    C25250 (NCI Thesaurus Property)
    C25604 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    DataEnteredDate
    Item
    Date worksheet entered into RDE
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C37949 (NCI Thesaurus Property)
    C1521975 (UMLS 2011AA Property)
    Item Group
    Death Assessment
    Date last contact
    Item
    Date of Death
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0805839 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C25461 (NCI Thesaurus Property)
    Item
    Contributing Cause of Death
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    C28554 (NCI Thesaurus ValueDomain-2)
    C0011065 (UMLS 2011AA ValueDomain-2)
    CL.1
    Code List
    Contributing Cause of Death
    CL Item
    Due To This Disease (Tumor)
    CL Item
    Due To Protocol Treatment ("Drug")
    CL Item
    Other Drug (Other Drug)
    CL Item
    Infection (Infection)
    CL Item
    Hemorrhage (Hemorrhage)
    CL Item
    ARDS (ARDS)
    CL Item
    Multi-Organ Failure (Multi-Organ Failure)
    CL Item
    GVHD (GVHD)
    CL Item
    Due To Other Cause, Specify (Other, Specify)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Primary cause of Death
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    C28554 (NCI Thesaurus ValueDomain-2)
    C0011065 (UMLS 2011AA ValueDomain-2)
    CL.2
    Code List
    Primary cause of Death
    CL Item
    Due To This Disease (Tumor)
    CL Item
    Due To Protocol Treatment ("Drug")
    CL Item
    Other Drug (Other Drug)
    CL Item
    Infection (Infection)
    CL Item
    Hemorrhage (Hemorrhage)
    CL Item
    ARDS (ARDS)
    CL Item
    Multi-Organ Failure (Multi-Organ Failure)
    CL Item
    GVHD (GVHD)
    CL Item
    Due To Other Cause, Specify (Other, Specify)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Cause of Death, specify
    Item
    please specify [primary cause of death] (If 'Other',)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0007465 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1521902 (UMLS CUI-2)
    C28554 (NCI Thesaurus Property)
    Cause of Death, specify
    Item
    please specify [primary cause of death] (If 'Other',)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0007465 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1521902 (UMLS CUI-2)
    C28554 (NCI Thesaurus Property)
    AutopsyPerformedInd-3
    Item
    Autopsy?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25153 (NCI Thesaurus ObjectClass)
    C0004398 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Item
    How were the side effects of protocol therapy related to the patient's death?
    text
    C28554 (NCI Thesaurus ObjectClass)
    C0011065 (UMLS 2011AA ObjectClass)
    C25320 (NCI Thesaurus Property)
    C1507394 (UMLS 2011AA Property)
    C25358 (NCI Thesaurus Property-2)
    C0596130 (UMLS 2011AA Property-2)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C28554 (NCI Thesaurus ValueDomain-2)
    C0011065 (UMLS 2011AA ValueDomain-2)
    CL.4
    Code List
    How were the side effects of protocol therapy related to the patient's death?
    CL Item
    Not Related (Not related)
    C25648 (NCI Thesaurus)
    C0439849 (UMLS 2011AA)
    C25594 (NCI Thesaurus-3)
    C1518422 (UMLS 2011AA-4)
    CL Item
    Minor Contribution To Death (Minor contributions to death)
    CL Item
    Major Contribution To Death (Major contributions to death)
    CL Item
    Exclusive Cause Of Death (Exclusive cause of death)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Item Group
    Ccrr Module For Acns0122 Death Worksheet
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