ID

11675

Beschreibung

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

Stichworte

  1. 20.09.12 20.09.12 -
  2. 28.07.15 28.07.15 - Julian Varghese
Hochgeladen am

28. Juli 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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Late Radiation Toxicity Form

No Instruction available.

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

Administrative Data

ECOG Protocol No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Patient ID
Beschreibung

ECOGPatientID

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Adverse Event Reporting From Date (M D Y)
Beschreibung

CTCAdverseEventReportBeginDate

Datentyp

date

Adverse Event Reporting To Date (M D Y)
Beschreibung

CTCAdverseEventReportEndDate

Datentyp

date

Patient?s Name
Beschreibung

Patient'sName

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Participating Group Patient ID
Beschreibung

ParticipatingGroupPatientID

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

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

AmendedDataInd

Datentyp

boolean

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

CTC Adverse Events and other Radiation

Unnamed (CTC Adverse Event Term)
Beschreibung

CTCAdverseEventTerm

Datentyp

text

CTC Adverse Event Grade
Beschreibung

CTCAdverseEventGrade

Datentyp

text

CTC Adverse Event Attribution Code
Beschreibung

CTCAdverseEventAttributionCode

Datentyp

text

AE Filed?
Beschreibung

ADRFiledInd

Datentyp

boolean

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

Radiation,other;specify

Datentyp

text

Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

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

InvestigatorSignatureDate

Datentyp

date

Ccrr Module For Late Radiation Toxicity Form
Beschreibung

Ccrr Module For Late Radiation Toxicity Form

Has an expedited AE report been filed?
Beschreibung

AdverseDrugExperienceReportingSystemReportFiledInd-3

Datentyp

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

Ähnliche Modelle

No Instruction available.

  1. StudyEvent: Late Radiation Toxicity Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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