ID

11662

Description

On-Study - North Central Cancer Treatment Group On-Study Form - 2467371v1.0 Stereotactic Radiation Therapy With or Without Whole-Brain Radiation Therapy in Treating Patients With Brain Metastases Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=104D18F2-219E-2AE1-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=104D18F2-219E-2AE1-E044-0003BA3F9857

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 7/25/15 7/25/15 - Martin Dugas
Uploaded on

July 25, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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    On-Study Form Brain Metastases NCT00377156

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: North Central Cancer Treatment Group On-Study Form
      1. No Instruction available.
    Header
    Description

    Header

    NCCTG Protocol Number
    Description

    Protocol ID NCCTG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1518419
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25581
    NCCTG Patient ID
    Description

    PatientNorthCentralCancerTreatmentGroupIdentifierNumber

    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
    C25581
    UMLS 2011AA Property-2
    C1518419
    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
    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
    Institution Number
    Description

    Institution Number

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Are data amended (If yes, highlight amended areas)
    Description

    Data amended

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Description Of Primary Disease
    Description

    Description Of Primary Disease

    MedDRA Code (primary tumor site: Metastases to brain parenchyma)
    Description

    MedDRACode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    NCI Thesaurus Property
    C25364
    NCI Metathesaurus ObjectClass
    CL104089
    UMLS CUI-1
    C1140263
    Disease/history
    Description

    Disease/history

    Primary Site (check one)
    Description

    BrainTumorPrimarySite

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12439
    UMLS 2011AA ObjectClass-2
    C0006104
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property-2
    C25251
    UMLS 2011AA Property-2
    C0205225
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    Other, specify
    Description

    BrainTumorPrimaryLocationSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12439
    UMLS 2011AA ObjectClass-2
    C0006104
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property-2
    C25251
    UMLS 2011AA Property-2
    C0205225
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Neurologic Examination
    Description

    Neurologic Examination

    Cranial nerves (check one)
    Description

    PatientCranialNerveNeurologicFunctionAssessmentStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property-2
    C25262
    UMLS 2011AA Property-2
    C0205494
    NCI Thesaurus Property-3
    C25518
    UMLS 2011AA Property-3
    C0542341
    NCI Thesaurus Property-4
    C12700
    UMLS 2011AA Property-4
    C0010268
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Sensation (check one)
    Description

    PatientSensoryNeurologicFunctionAssessmentStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property-2
    C25262
    UMLS 2011AA Property-2
    C0205494
    NCI Thesaurus Property-3
    C25518
    UMLS 2011AA Property-3
    C0542341
    NCI Thesaurus Property-4
    C28259
    UMLS 2011AA Property-4
    C0445254
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Motor (check one)
    Description

    PatientMotorNeurologicFunctionAssessmentStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property-2
    C25262
    UMLS 2011AA Property-2
    C0205494
    NCI Thesaurus Property-3
    C25518
    UMLS 2011AA Property-3
    C0542341
    NCI Thesaurus Property-4
    C28367
    UMLS 2011AA Property-4
    C1513492
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Cerebellar (check one)
    Description

    PatientCerebellumNeurologicFunctionAssessmentStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property-2
    C25262
    UMLS 2011AA Property-2
    C0205494
    NCI Thesaurus Property-3
    C25518
    UMLS 2011AA Property-3
    C0542341
    NCI Thesaurus Property-4
    C12445
    UMLS 2011AA Property-4
    C0007765
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Height
    Description

    Height

    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
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    No Instruction available.

    1 forms
    1. StudyEvent: North Central Cancer Treatment Group On-Study Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Protocol ID NCCTG
    Item
    NCCTG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1518419 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25581 (NCI Thesaurus Property-2)
    PatientNorthCentralCancerTreatmentGroupIdentifierNumber
    Item
    NCCTG 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)
    C25581 (NCI Thesaurus Property-2)
    C1518419 (UMLS 2011AA Property-2)
    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
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Institution Number
    Item
    Institution Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Data amended
    Item
    Are data amended (If yes, highlight amended areas)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    Description Of Primary Disease
    MedDRA
    Item
    MedDRA Code (primary tumor site: Metastases to brain parenchyma)
    text
    C25162 (NCI Thesaurus ValueDomain)
    C25364 (NCI Thesaurus Property)
    CL104089 (NCI Metathesaurus ObjectClass)
    C1140263 (UMLS CUI-1)
    Item Group
    Disease/history
    Item
    Primary Site (check one)
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12439 (NCI Thesaurus ObjectClass-2)
    C0006104 (UMLS 2011AA ObjectClass-2)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25251 (NCI Thesaurus Property-2)
    C0205225 (UMLS 2011AA Property-2)
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Primary Site (check one)
    CL Item
    Breast (breast)
    C12971 (NCI Thesaurus)
    C0006141 (UMLS 2011AA)
    CL Item
    Colorectal (Colorectal)
    C13363 (NCI Thesaurus)
    C0555952 (UMLS 2011AA)
    CL Item
    Lung (lung)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    CL Item
    Skin/melanoma (skin/melanoma)
    CL Item
    Prostate Gland (Prostate)
    C12410 (NCI Thesaurus)
    C0033572 (UMLS 2011AA)
    CL Item
    Bladder (Bladder)
    C12414 (NCI Thesaurus)
    C0005682 (UMLS 2011AA)
    CL Item
    Kidney (Kidney)
    C12415 (NCI Thesaurus)
    C0022646 (UMLS 2011AA)
    CL Item
    Sarcoma (Sarcoma)
    C9118 (NCI Thesaurus)
    C1261473 (UMLS 2011AA)
    CL Item
    Gynecologic (Gynecologic)
    C28016 (NCI Thesaurus)
    C0205480 (UMLS 2011AA)
    CL Item
    Other Specify (other)
    BrainTumorPrimaryLocationSpecify
    Item
    Other, specify
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12439 (NCI Thesaurus ObjectClass-2)
    C0006104 (UMLS 2011AA ObjectClass-2)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25251 (NCI Thesaurus Property-2)
    C0205225 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item Group
    Neurologic Examination
    Item
    Cranial nerves (check one)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25262 (NCI Thesaurus Property-2)
    C0205494 (UMLS 2011AA Property-2)
    C25518 (NCI Thesaurus Property-3)
    C0542341 (UMLS 2011AA Property-3)
    C12700 (NCI Thesaurus Property-4)
    C0010268 (UMLS 2011AA Property-4)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.3
    Code List
    Cranial nerves (check one)
    CL Item
    Abnormal (Abnormal)
    C25401 (NCI Thesaurus)
    C0205161 (UMLS 2011AA)
    CL Item
    Normal (Normal)
    C14165 (NCI Thesaurus)
    C0205307 (UMLS 2011AA)
    Item
    Sensation (check one)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25262 (NCI Thesaurus Property-2)
    C0205494 (UMLS 2011AA Property-2)
    C25518 (NCI Thesaurus Property-3)
    C0542341 (UMLS 2011AA Property-3)
    C28259 (NCI Thesaurus Property-4)
    C0445254 (UMLS 2011AA Property-4)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Sensation (check one)
    CL Item
    Abnormal (Abnormal)
    C25401 (NCI Thesaurus)
    C0205161 (UMLS 2011AA)
    CL Item
    Normal (Normal)
    C14165 (NCI Thesaurus)
    C0205307 (UMLS 2011AA)
    Item
    Motor (check one)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25262 (NCI Thesaurus Property-2)
    C0205494 (UMLS 2011AA Property-2)
    C25518 (NCI Thesaurus Property-3)
    C0542341 (UMLS 2011AA Property-3)
    C28367 (NCI Thesaurus Property-4)
    C1513492 (UMLS 2011AA Property-4)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Motor (check one)
    CL Item
    Abnormal (Abnormal)
    C25401 (NCI Thesaurus)
    C0205161 (UMLS 2011AA)
    CL Item
    Normal (Normal)
    C14165 (NCI Thesaurus)
    C0205307 (UMLS 2011AA)
    Item
    Cerebellar (check one)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25262 (NCI Thesaurus Property-2)
    C0205494 (UMLS 2011AA Property-2)
    C25518 (NCI Thesaurus Property-3)
    C0542341 (UMLS 2011AA Property-3)
    C12445 (NCI Thesaurus Property-4)
    C0007765 (UMLS 2011AA Property-4)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.6
    Code List
    Cerebellar (check one)
    CL Item
    Abnormal (Abnormal)
    C25401 (NCI Thesaurus)
    C0205161 (UMLS 2011AA)
    CL Item
    Normal (Normal)
    C14165 (NCI Thesaurus)
    C0205307 (UMLS 2011AA)
    Item Group
    Height
    Height
    Item
    Height
    float
    C25209 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0005890 (UMLS CUI-1)
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