ID

11675

Description

Late Radiation Toxicity Form Gemcitabine With or Without Radiation Therapy in Treating Patients With Pancreatic Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A65CC822-2E9B-42C2-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A65CC822-2E9B-42C2-E034-0003BA0B1A09

Keywords

Versions (2)
  1. 9/20/12 9/20/12 -
  2. 7/28/15 7/28/15 - Julian Varghese
Uploaded on

July 28, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Late Radiation Toxicity Form

English

No Instruction available.

1 forms  
  1. StudyEvent: Late Radiation Toxicity Form
    1. No Instruction available.
Administrative Data
Description

Administrative Data

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient ID
Description

ECOGPatientID

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Adverse Event Reporting From Date (M D Y)
Description

CTCAdverseEventReportBeginDate

Data type

date

Adverse Event Reporting To Date (M D Y)
Description

CTCAdverseEventReportEndDate

Data type

date

Patient?s Name
Description

Patient'sName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Are data amended? (If yes, please circle amended items in red)
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
CTC Adverse Events and other Radiation
Description

CTC Adverse Events and other Radiation

Unnamed (CTC Adverse Event Term)
Description

CTCAdverseEventTerm

Data type

text

CTC Adverse Event Grade
Description

CTCAdverseEventGrade

Data type

text

CTC Adverse Event Attribution Code
Description

CTCAdverseEventAttributionCode

Data type

text

AE Filed?
Description

ADRFiledInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25410
UMLS 2011AA ObjectClass
C1521800
NCI Thesaurus Property
C25175
UMLS 2011AA Property
C1522646
Radiation, other; specify
Description

Radiation,other;specify

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Investigator Signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Description

InvestigatorSignatureDate

Data type

date

Ccrr Module For Late Radiation Toxicity Form
Description

Ccrr Module For Late Radiation Toxicity Form

Has an expedited AE report been filed?
Description

AdverseDrugExperienceReportingSystemReportFiledInd-3

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Metathesaurus ObjectClass
C0085425
NCI Thesaurus Property
C25175
UMLS 2011AA Property
C1522646
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Late Radiation Toxicity Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Data
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
RegistrationStep
Item
Registration Step
text
CTCAdverseEventReportBeginDate
Item
Adverse Event Reporting From Date (M D Y)
date
CTCAdverseEventReportEndDate
Item
Adverse Event Reporting To Date (M D Y)
date
Patient'sName
Item
Patient?s Name
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
AmendedDataInd
Item
Are data amended? (If yes, please circle amended items in red)
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
CTC Adverse Events and other Radiation
CTCAdverseEventTerm
Item
Unnamed (CTC Adverse Event Term)
text
CTCAdverseEventGrade
Item
CTC Adverse Event Grade
text
CTCAdverseEventAttributionCode
Item
CTC Adverse Event Attribution Code
text
ADRFiledInd
Item
AE Filed?
boolean
C25410 (NCI Thesaurus ObjectClass)
C1521800 (UMLS 2011AA ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
Radiation,other;specify
Item
Radiation, other; specify
text
Item Group
Comments
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Late Radiation Toxicity Form
AdverseDrugExperienceReportingSystemReportFiledInd-3
Item
Has an expedited AE report been filed?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C0085425 (NCI Metathesaurus ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
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