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11654

Description

CALGB: 90104 Chemotherapy Dose Form Combination Chemotherapy in Treating Patients With Bladder Cancer NCT00014534 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1C0B11-7B76-737C-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1C0B11-7B76-737C-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/3/15 1/3/15 - Martin Dugas
  3. 7/25/15 7/25/15 - Martin Dugas
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July 25, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Bladder Cancer CALGB 90104 NCT00014534

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: CALGB: 90104 Chemotherapy Dose Form
      1. No Instruction available.
    Chemotherapy Dose Form
    Description

    Chemotherapy Dose Form

    CALGB Form
    Description

    CALGB Form

    Data type

    text

    Alias
    UMLS CUI-1
    C3262252
    UMLS CUI-2
    C1516238
    CALGB Study No.
    Description

    Protocol ID CALGB

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    CALGB Patient ID
    Description

    Trial subject ID CALGB

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    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
    Participating group
    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
    Patient medical record number
    Description

    Medical Record Number

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301894
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25261
    NCI Thesaurus Property-2
    C25198
    Participating group protocol number
    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
    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
    Participating Group Patient 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
    Height
    Description

    Height

    Data type

    float

    Measurement units
    • cm
    Alias
    NCI Thesaurus ValueDomain
    C25209
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25347
    UMLS CUI-1
    C0005890
    cm
    Body weight
    Description

    Body weight

    Data type

    float

    Measurement units
    • kg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25208
    UMLS CUI-1
    C0005910
    kg
    Body surface area
    Description

    Body surface area

    Data type

    float

    Measurement units
    • m²
    Alias
    NCI Thesaurus ValueDomain
    C25209
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25157
    UMLS CUI-1
    C0005902
    m²
    Cycle number
    Description

    Cycle Number Chemotherapeutics

    Data type

    integer

    Alias
    UMLS CUI-1
    C2045829
    Date of First Day of Cycle
    Description

    Chemotherapy Cycle Start Date

    Data type

    date

    Alias
    UMLS CUI-1
    C1302181
    UMLS CUI-2
    C3173309
    Last date Drugs administered
    Description

    Chemotherapy Cycle End Date

    Data type

    date

    Alias
    UMLS CUI-1
    C1302181
    UMLS CUI-2
    C0806020
    Drug Code
    Description

    Drug Code

    Data type

    text

    Alias
    UMLS CUI-1
    C1708005
    Agent Name
    Description

    Agent

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus ValueDomain
    C1708
    NCI Thesaurus ValueDomain-2
    C42614
    UMLS CUI-1
    C1521826
    Total dose received this cycle
    Description

    Agent Total Dose

    Data type

    float

    Alias
    NCI Thesaurus ValueDomain
    C25304
    UMLS CUI-1
    C2986497
    NCI Thesaurus Property
    C25379
    NCI Thesaurus ValueDomain-2
    C25488
    NCI Thesaurus ObjectClass
    C1708
    Units
    Description

    Units

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C1708
    UMLS CUI-1
    C1519795
    NCI Thesaurus Property
    C25256
    NCI Thesaurus ValueDomain
    C25709
    Dose Modified?
    Description

    Dose Modification

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS CUI-1
    C1707811
    NCI Thesaurus ObjectClass
    C25256
    NCI Thesaurus Property
    C25572
    NCI Thesaurus ValueDomain-2
    C25572
    If yes, why
    Description

    Reason for Therapy Modification

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS CUI-1
    C1299575
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25572
    Dose Delayed?
    Description

    Chemotherapy delayed

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C1299577
    NCI Thesaurus Property
    C25477
    NCI Thesaurus Property-2
    C25472
    NCI Thesaurus ObjectClass
    C15368
    If yes, why
    Description

    Reason for treatment delay

    Data type

    text

    Alias
    UMLS CUI-1
    C1298642
    If why, specify (why dose delayed)
    Description

    Reason for treatment delay, specify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C1298642
    NCI Thesaurus Property
    C25477
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus Property-2
    C25409
    completed by
    Description

    Person Completing Form

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    date form completed
    Description

    Date Form Completed

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1115437
    NCI Thesaurus ObjectClass
    C40988
    NCI Thesaurus Property
    C25250
    NCI Thesaurus ValueDomain-2
    C25367
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: CALGB: 90104 Chemotherapy Dose Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Chemotherapy Dose Form
    CALGB Form
    Item
    CALGB Form
    text
    C3262252 (UMLS CUI-1)
    C1516238 (UMLS CUI-2)
    Protocol ID CALGB
    Item
    CALGB Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    Trial subject ID CALGB
    Item
    CALGB Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Participating Group
    Item
    Participating group
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Medical Record Number
    Item
    Patient medical record number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301894 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25261 (NCI Thesaurus Property)
    C25198 (NCI Thesaurus Property-2)
    Study Number Participating Group
    Item
    Participating group protocol number
    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)
    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)
    Trial subject ID Participating Group
    Item
    Participating Group Patient 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)
    Height
    Item
    Height
    float
    C25209 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0005890 (UMLS CUI-1)
    Weight
    Item
    Body weight
    float
    C25209 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25208 (NCI Thesaurus Property)
    C0005910 (UMLS CUI-1)
    BSA
    Item
    Body surface area
    float
    C25209 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25157 (NCI Thesaurus Property)
    C0005902 (UMLS CUI-1)
    Cycle Number Chemotherapeutics
    Item
    Cycle number
    integer
    C2045829 (UMLS CUI-1)
    Chemotherapy Cycle Start Date
    Item
    Date of First Day of Cycle
    date
    C1302181 (UMLS CUI-1)
    C3173309 (UMLS CUI-2)
    Chemotherapy Cycle End Date
    Item
    Last date Drugs administered
    date
    C1302181 (UMLS CUI-1)
    C0806020 (UMLS CUI-2)
    Drug Code
    Item
    Drug Code
    text
    C1708005 (UMLS CUI-1)
    Agent
    Item
    Agent Name
    text
    C25364 (NCI Thesaurus Property)
    C1708 (NCI Thesaurus ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C42614 (NCI Thesaurus ValueDomain-2)
    C1521826 (UMLS CUI-1)
    Agent Total Dose
    Item
    Total dose received this cycle
    float
    C25304 (NCI Thesaurus ValueDomain)
    C2986497 (UMLS CUI-1)
    C25379 (NCI Thesaurus Property)
    C25488 (NCI Thesaurus ValueDomain-2)
    C1708 (NCI Thesaurus ObjectClass)
    Item
    Units
    text
    C1708 (NCI Thesaurus ObjectClass)
    C1519795 (UMLS CUI-1)
    C25256 (NCI Thesaurus Property)
    C25709 (NCI Thesaurus ValueDomain)
    CL.1
    Code List
    Units
    CL Item
    Gram (grams)
    C0439208 (NCI Metathesaurus)
    CL Item
    Meter (milligrams)
    C0475209 (NCI Metathesaurus)
    CL Item
    Microgram (micrograms)
    CL Item
    Liter (liters)
    CL Item
    Milliliter (milliliters)
    C28254 (NCI Thesaurus)
    C0439242 (UMLS 2011AA)
    CL Item
    Unit (units)
    C44278 (NCI Thesaurus)
    C0439148 (UMLS 2011AA)
    CL Item
    International Unit (international units)
    C28255 (NCI Thesaurus)
    Item
    Dose Modified?
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1707811 (UMLS CUI-1)
    C25256 (NCI Thesaurus ObjectClass)
    C25572 (NCI Thesaurus Property)
    C25572 (NCI Thesaurus ValueDomain-2)
    CL.2
    Code List
    Dose Modified?
    CL Item
    No (no)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Planned (i.e., The Treatment Was Changed According To Protocol Guidelines) (yes, planned)
    CL Item
    Yes, Unplanned (i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (yes, unplanned)
    Item
    If yes, why
    text
    C25638 (NCI Thesaurus ValueDomain)
    C1299575 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25572 (NCI Thesaurus Property)
    CL.3
    Code List
    If yes, why
    CL Item
    hematologic tox (hematologic tox)
    CL Item
    hepatic dys (hepatic dys)
    CL Item
    PNS toxicity (PNS toxicity)
    CL Item
    CNS toxicity (CNS toxicity)
    CL Item
    GI toxicity (GI toxicity)
    CL Item
    cardiotoxicity (cardiotoxicity)
    CL Item
    pulmonary toxicity (pulmonary toxicity)
    CL Item
    renal toxicity (renal toxicity)
    CL Item
    infection/fever (infection/fever)
    CL Item
    other (other)
    Item
    Dose Delayed?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1299577 (UMLS CUI-1)
    C25477 (NCI Thesaurus Property)
    C25472 (NCI Thesaurus Property-2)
    C15368 (NCI Thesaurus ObjectClass)
    CL.4
    Code List
    Dose Delayed?
    CL Item
    No (no)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (yes, unplanned)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Yes (yes, planned)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    If yes, why
    text
    C1298642 (UMLS CUI-1)
    CL.5
    Code List
    If yes, why
    CL Item
    Cycle Was Delayed Due To Hematologic Toxicity (hematologic tox)
    CL Item
    hepatic dys (hepatic dys)
    CL Item
    PNS toxicity (PNS toxicity)
    CL Item
    CNS toxicity (CNS toxicity)
    CL Item
    GI toxicity (GI toxicity)
    CL Item
    cardiotoxicity (cardiotoxicity)
    CL Item
    pulmonary toxicity (pulmonary toxicity)
    CL Item
    Cycle Was Delayed Due To Renal Toxicity (renal toxicity)
    CL Item
    infection/fever (infection/fever)
    CL Item
    other (other)
    Reason for treatment delay, specify
    Item
    If why, specify (why dose delayed)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1298642 (UMLS CUI-1)
    C25477 (NCI Thesaurus Property)
    C1708 (NCI Thesaurus ObjectClass)
    C25409 (NCI Thesaurus Property-2)
    Person Completing Form
    Item
    completed by
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Date Form Completed
    Item
    date form completed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1115437 (UMLS CUI-1)
    C40988 (NCI Thesaurus ObjectClass)
    C25250 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)
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