ID

11482

Description

SOUTHWEST ONCOLOGY GROUP NOTICE OF DEATH (S0230)NCT00068601 Goserelin in Preventing Ovarian Failure in Women Receiving Chemotherapy for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BEA922CE-409A-2413-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BEA922CE-409A-2413-E034-0003BA12F5E7

Keywords

  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/5/15 7/5/15 -
Uploaded on

July 5, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :


    No comments

    In order to download data models you must be logged in. Please log in or register for free.

    SOUTHWEST ONCOLOGY GROUP NOTICE OF DEATH (S0230) NCT00068601

    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.

    Header
    Description

    Header

    SWOG Patient ID
    Description

    Trial subject ID SWOG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    Most Recent SWOG Study No.
    Description

    MostRecentSWOGStudyNo.

    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/Affiliate
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Physician (Groups other than SWOG)
    Description

    Investigator Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2826892
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C17089
    NCI Thesaurus ObjectClass-2
    C25644
    Group Name
    Description

    Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2347449
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    Study No.
    Description

    Study Number Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Pt. ID
    Description

    Trial subject ID Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Date of death
    Description

    Date of death

    Date of Death (month / day / year)
    Description

    DeathDocumentedDate

    Data type

    date

    Causes Of Death
    Description

    Causes Of Death

    Any cancer (select one)
    Description

    Anycancer

    Data type

    text

    If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
    Description

    PersonCancerAssociatedDeathType

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C28554
    UMLS 2011AA Property
    C0011065
    NCI Thesaurus Property-2
    C9305
    UMLS 2011AA Property-2
    C0006826
    NCI Thesaurus Property-3
    C25281
    UMLS 2011AA Property-3
    C0332281
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Cancer of most recent SWOG study, specify cancer
    Description

    CancerofmostrecentSWOGstudy,specifycancer

    Data type

    text

    Cancer of other SWOG study, specify cancer
    Description

    CancerofotherSWOGstudy,specifycancer

    Data type

    text

    Other cancer, specify
    Description

    Othercancer,specify

    Data type

    text

    Toxicity from disease related treatment (select one)
    Description

    Toxicityfromdiseaserelatedtreatment

    Data type

    text

    If Primary Cause, Contributory or Possible, specify treatment and toxicity
    Description

    IfPrimaryCause,ContributoryorPossible,specifytreatmentandtoxicity

    Data type

    text

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

    Non-cancerandnon-treatmentrelatedcauses

    Data type

    text

    If Primary Cause, Contributory or Possible, specify
    Description

    IfPrimaryCause,ContributoryorPossible,specify

    Data type

    text

    Autopsy?
    Description

    AutopsyPerformedInd-3

    Data type

    text

    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
    Source of death information (select all that apply)
    Description

    DeathInformationSource

    Data type

    text

    Other, specify
    Description

    PatientDeathSourceSpecify

    Data type

    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
    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 Southwest Oncology Group Notice Of Death (s0230)
    Description

    Ccrr Module For Southwest Oncology Group Notice Of Death (s0230)

    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.

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Trial subject ID SWOG
    Item
    SWOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    MostRecentSWOGStudyNo.
    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)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Investigator Name
    Item
    Physician (Groups other than SWOG)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2826892 (UMLS CUI-1)
    C25364 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    C25644 (NCI Thesaurus ObjectClass-2)
    Participating Group
    Item
    Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Pt. ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Item Group
    Date of death
    DeathDocumentedDate
    Item
    Date of Death (month / day / year)
    date
    Item Group
    Causes Of Death
    Item
    Any cancer (select one)
    text
    Code List
    Any cancer (select one)
    CL Item
    No2005686 (No)
    CL Item
    Primary_cause2005687 (Primary Cause)
    CL Item
    Contributory2005688 (Contributory)
    CL Item
    Possible2005689 (Possible)
    CL Item
    Unknown2005690 (Unknown)
    Item
    If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    C9305 (NCI Thesaurus Property-2)
    C0006826 (UMLS 2011AA Property-2)
    C25281 (NCI Thesaurus Property-3)
    C0332281 (UMLS 2011AA Property-3)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
    CL Item
    Cancer_of_most_recent_s2005692 (Cancer of most recent SWOG study, specify cancer)
    CL Item
    Cancer_of_oth_swog_stdy2005693 (Cancer of other SWOG study, specify cancer)
    CL Item
    Other_cancer_specify2005694 (Other cancer, specify)
    CancerofmostrecentSWOGstudy,specifycancer
    Item
    Cancer of most recent SWOG study, specify cancer
    text
    CancerofotherSWOGstudy,specifycancer
    Item
    Cancer of other SWOG study, specify cancer
    text
    Othercancer,specify
    Item
    Other cancer, specify
    text
    Item
    Toxicity from disease related treatment (select one)
    text
    Code List
    Toxicity from disease related treatment (select one)
    CL Item
    No2005697 (No)
    CL Item
    Primary_cause2005698 (Primary Cause)
    CL Item
    Contributory2005699 (Contributory)
    CL Item
    Possible2005700 (Possible)
    CL Item
    Unknown2005701 (Unknown)
    IfPrimaryCause,ContributoryorPossible,specifytreatmentandtoxicity
    Item
    If Primary Cause, Contributory or Possible, specify treatment and toxicity
    text
    Item
    Non-cancer and non-treatment related causes (select one)
    text
    Code List
    Non-cancer and non-treatment related causes (select one)
    CL Item
    No2005705 (No)
    CL Item
    Primary_cause2005706 (Primary Cause)
    CL Item
    Contributory2005707 (Contributory)
    CL Item
    Possible2005708 (Possible)
    CL Item
    Unknown2005709 (Unknown)
    IfPrimaryCause,ContributoryorPossible,specify
    Item
    If Primary Cause, Contributory or Possible, specify
    text
    Item
    Autopsy?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25153 (NCI Thesaurus ObjectClass)
    C0004398 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Code List
    Autopsy?
    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
    Source of death information (select all that apply)
    text
    Code List
    Source of death information (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
    Clinical Evidence Was The Source Of Information On The Patient's Death (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
    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 Southwest Oncology Group Notice Of Death (s0230)

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial