ID

11675

Beschrijving

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

Trefwoorden

  1. 20-09-12 20-09-12 -
  2. 28-07-15 28-07-15 - Julian Varghese
Geüploaded op

28 juli 2015

DOI

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Licentie

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
    Beschrijving

    Administrative Data

    ECOG Protocol No.
    Beschrijving

    ECOGProtocolNo.

    Datatype

    text

    ECOG Patient ID
    Beschrijving

    ECOGPatientID

    Datatype

    text

    Registration Step
    Beschrijving

    RegistrationStep

    Datatype

    text

    Adverse Event Reporting From Date (M D Y)
    Beschrijving

    CTCAdverseEventReportBeginDate

    Datatype

    date

    Adverse Event Reporting To Date (M D Y)
    Beschrijving

    CTCAdverseEventReportEndDate

    Datatype

    date

    Patient?s Name
    Beschrijving

    Patient'sName

    Datatype

    text

    Participating Group Protocol No.
    Beschrijving

    ParticipatingGroupProtocolNo.

    Datatype

    text

    Participating Group Patient ID
    Beschrijving

    ParticipatingGroupPatientID

    Datatype

    text

    Institution/Affiliate
    Beschrijving

    MainMemberInstitution/Affiliate

    Datatype

    text

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

    AmendedDataInd

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    UMLS 2011AA ObjectClass
    C1511726 (Data)
    NCI Thesaurus Property
    C25416 (undefined)
    UMLS 2011AA Property
    C1691222 (Amended)
    CTC Adverse Events and other Radiation
    Beschrijving

    CTC Adverse Events and other Radiation

    Unnamed (CTC Adverse Event Term)
    Beschrijving

    CTCAdverseEventTerm

    Datatype

    text

    CTC Adverse Event Grade
    Beschrijving

    CTCAdverseEventGrade

    Datatype

    text

    CTC Adverse Event Attribution Code
    Beschrijving

    CTCAdverseEventAttributionCode

    Datatype

    text

    AE Filed?
    Beschrijving

    ADRFiledInd

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25410 (undefined)
    UMLS 2011AA ObjectClass
    C1521800 (Adverse Drug Experience Report)
    NCI Thesaurus Property
    C25175 (undefined)
    UMLS 2011AA Property
    C1522646 (Filed)
    Radiation, other; specify
    Beschrijving

    Radiation,other;specify

    Datatype

    text

    Comments
    Beschrijving

    Comments

    Comments
    Beschrijving

    Comments

    Datatype

    text

    Investigator Signature
    Beschrijving

    InvestigatorSignature

    Datatype

    text

    Alias
    NCI Thesaurus Property
    C25678 (undefined)
    UMLS 2011AA Property
    C1519316 (Signature)
    LOINC
    LP248948-4
    NCI Thesaurus ObjectClass
    C17089 (undefined)
    UMLS 2011AA ObjectClass
    C0035173 (Research Personnel)
    SNOMED
    769038007
    LOINC
    LA23773-7
    Date
    Beschrijving

    InvestigatorSignatureDate

    Datatype

    date

    Ccrr Module For Late Radiation Toxicity Form
    Beschrijving

    Ccrr Module For Late Radiation Toxicity Form

    Has an expedited AE report been filed?
    Beschrijving

    AdverseDrugExperienceReportingSystemReportFiledInd-3

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS 2011AA ValueDomain
    C1512699 (Yes, No, or Unknown Response)
    NCI Thesaurus ObjectClass
    C25375 (undefined)
    UMLS 2011AA ObjectClass
    C0684224 (Report (document))
    SNOMED
    229059009
    LOINC
    LP183761-8
    NCI Metathesaurus ObjectClass
    C0085425 (Adverse Drug Reaction Reporting Systems)
    NCI Thesaurus Property
    C25175 (undefined)
    UMLS 2011AA Property
    C1522646 (Filed)

    Similar models

    No Instruction available.

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