ID

11499

Beschreibung

NCT00087178 NSABP PROTOCOL B-36 Form CFMD Missing Data Form for One-Year Cardiac Function Assessment Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F4191978-F435-325C-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F4191978-F435-325C-E034-0003BA3F9857

Stichworte

Klinische Studie [Dokumenttyp]

Mammatumoren, Mensch

Hochgeladen am

5. Juli 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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NCT00087178 NSABP PROTOCOL B-36 Form CFMD Missing Data Form for One-Year Cardiac Function Assessment

Modell
Details

Submit this form to the NSABP Biostatistical Center whenever a one-year cardiac function assessment (LVEF) is not obtained. No missing data form is required for patients who have died or had a documented breast cancer or a second primary cancer during the first year on study. Fax to 412-622-2111

1 Formulare

StudyEvent: NSABP PROTOCOL B-36 Form CFMD Missing Data Form for One-Year Cardiac Function Assessment
1. Submit this form to the NSABP Biostatistical Center whenever a one-year cardiac function assessment (LVEF) is not obtained. No missing data form is required for patients who have died or had a documented breast cancer or a second primary cancer during the first year on study. Fax to 412-622-2111

Header module

Beschreibung

Header module

Patient Initials (Last, First Middle)

Beschreibung

Patient Initials

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C2986440

NCI Thesaurus ObjectClass: C16960

NCI Thesaurus Property: C25536

Patient ID Number

Beschreibung

Patient ID NSABP

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS CUI-1: C2348585

NCI Thesaurus ObjectClass: C16960

UMLS CUI-2: C1513905

NCI Thesaurus Property: C25364

NCI Thesaurus Property-2: C15818

Institution Name

Beschreibung

Institution Name

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C1301943

NCI Thesaurus ObjectClass: C21541

NCI Thesaurus ValueDomain-2: C21541

NCI Thesaurus Property: C25364

Affiliate Name

Beschreibung

Affiliate Name

Datentyp

text

Alias

NCI Thesaurus ObjectClass: C21541

UMLS CUI-1: C1510825

NCI Thesaurus ObjectClass-2: C25413

NCI Thesaurus Property: C25364

NCI Thesaurus ValueDomain: C25191

NCI Thesaurus ValueDomain-2: C21541

Person Completing Form (Last Name)

Beschreibung

Person Completing Form Last Name

Datentyp

text

Alias

NCI Thesaurus ObjectClass: C25190

UMLS CUI-1: C1550483

NCI Thesaurus ObjectClass-2: C25657

UMLS CUI-2: C1301584

NCI Thesaurus Property: C25364

NCI Thesaurus Property-2: C25551

NCI Thesaurus ValueDomain: C25191

Person Completing Form (First Name)

Beschreibung

Person Completing Form First Name

Datentyp

text

Alias

NCI Thesaurus ObjectClass: C25190

UMLS CUI-1: C1550483

NCI Thesaurus ObjectClass-2: C25657

UMLS CUI-2: C1443235

NCI Thesaurus Property: C25364

NCI Thesaurus Property-2: C25509

NCI Thesaurus ValueDomain: C25191

Person Completing Form (Phone)

Beschreibung

Person Completing Form Phone

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS CUI-1: C1550483

NCI Thesaurus ObjectClass: C25190

UMLS CUI-2: C1515258

NCI Thesaurus ObjectClass-2: C25657

NCI Thesaurus Property: C25395

Today's date (Month Day Year)

Beschreibung

Today'sDate

Datentyp

text

Are data amended?

Beschreibung

Data amended

Datentyp

boolean

Alias

NCI Thesaurus ValueDomain: C38148

UMLS CUI-1: C0680532

NCI Thesaurus ObjectClass: C25474

NCI Thesaurus Property: C25416

Yes

Cardiac Performance Status

Beschreibung

Cardiac Performance Status

Reason Cardiac Function was not Assessed (Mark the main reason. If necessary, add comments below.)

Beschreibung

CardiacPerformanceStatusAssessmentNotPerformedReason

Datentyp

text

Alias

NCI Thesaurus ObjectClass: C13306

UMLS 2011AA ObjectClass: C1522601

NCI Metathesaurus ObjectClass: CL092952

NCI Thesaurus Property: C20989

UMLS 2011AA Property: C0031809

NCI Thesaurus ValueDomain: C25638

UMLS 2011AA ValueDomain: C0392360

NCI Metathesaurus ValueDomain: CL213997

Patient Refused Assessment Or Was Unavailable Because Of Illness Or Emotional Upset (Patient refused assessment or was unavailable because of illness or emotional upset)

Patient Refused Assessment Or Was Unavailable For A Reason Other Than Illness Or Upset (Patient refused assessment or was unavailable for a reason other than illness or upset)

Staff Concerned For Patient's Medical Or Emotional Condition (Staff concerned for patient's medical or emotional condition)

Staff Oversight Or Understaffing (Staff oversight or understaffing)

Comments

Beschreibung

Comments

Comments (optional)

Beschreibung

Research Comments

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25704

UMLS CUI-1: C0947611

NCI Thesaurus ObjectClass: C15319

NCI Thesaurus Property: C25393

Zum Seitenanfang zurückkehren

Submit this form to the NSABP Biostatistical Center whenever a one-year cardiac function assessment (LVEF) is not obtained. No missing data form is required for patients who have died or had a documented breast cancer or a second primary cancer during the first year on study. Fax to 412-622-2111

1 Formulare

StudyEvent: NSABP PROTOCOL B-36 Form CFMD Missing Data Form for One-Year Cardiac Function Assessment
1. Submit this form to the NSABP Biostatistical Center whenever a one-year cardiac function assessment (LVEF) is not obtained. No missing data form is required for patients who have died or had a documented breast cancer or a second primary cancer during the first year on study. Fax to 412-622-2111

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Header module

Item Group

Header module

Patient Initials

Item

Patient Initials (Last, First Middle)

text

C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)

Patient ID NSABP

Item

Patient ID Number

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)

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)

Affiliate Name

Item

Affiliate Name

text

C21541 (NCI Thesaurus ObjectClass)
C1510825 (UMLS CUI-1)
C25413 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)

Person Completing Form Last Name

Item

Person Completing Form (Last Name)

text

C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)

Person Completing Form First Name

Item

Person Completing Form (First Name)

text

C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1443235 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)

Person Completing Form Phone

Item

Person Completing Form (Phone)

text

C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)

Today'sDate

Item

Today's date (Month Day Year)

text

Data amended

Item

Are data amended?

boolean

C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)

Cardiac Performance Status

Item Group

Cardiac Performance Status

CardiacPerformanceStatusAssessmentNotPerformedReason

Item

Reason Cardiac Function was not Assessed (Mark the main reason. If necessary, add comments below.)

text

C13306 (NCI Thesaurus ObjectClass)
C1522601 (UMLS 2011AA ObjectClass)
CL092952 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL213997 (NCI Metathesaurus ValueDomain)

CL.2

Code List

Reason Cardiac Function was not Assessed (Mark the main reason. If necessary, add comments below.)

CL Item

Patient Refused Assessment Or Was Unavailable Because Of Illness Or Emotional Upset (Patient refused assessment or was unavailable because of illness or emotional upset)

CL Item

Patient Refused Assessment Or Was Unavailable For A Reason Other Than Illness Or Upset (Patient refused assessment or was unavailable for a reason other than illness or upset)

CL Item

Staff Concerned For Patient's Medical Or Emotional Condition (Staff concerned for patient's medical or emotional condition)

CL Item

Staff Oversight Or Understaffing (Staff oversight or understaffing)

Comments

Item Group

Comments

Research Comments

Item

Comments (optional)

text

C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)

Zum Seitenanfang zurückkehren

ID

Beschreibung

Link

Stichworte

Versionen (3)

Hochgeladen am

DOI

Lizenz

Modell Kommentare :

Itemgroup Kommentare für :

Item Kommentare für :

NCT00087178 NSABP PROTOCOL B-36 Form CFMD Missing Data Form for One-Year Cardiac Function Assessment

Submit this form to the NSABP Biostatistical Center whenever a one-year cardiac function assessment (LVEF) is not obtained. No missing data form is required for patients who have died or had a documented breast cancer or a second primary cancer during the first year on study. Fax to 412-622-2111

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Ähnliche Modelle

Submit this form to the NSABP Biostatistical Center whenever a one-year cardiac function assessment (LVEF) is not obtained. No missing data form is required for patients who have died or had a documented breast cancer or a second primary cancer during the first year on study. Fax to 412-622-2111

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