ID

11697

Description

ECOG Nontarget Lesions Supplemental Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC328486-403E-246F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC328486-403E-246F-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 8/27/12 8/27/12 -
  2. 5/23/15 5/23/15 -
  3. 7/28/15 7/28/15 - Julian Varghese
Uploaded on

July 28, 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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ECOG Nontarget Lesions Supplemental Form (E2100)

English

Form No. 1565

1 forms  
  1. StudyEvent: ECOG Nontarget Lesions Supplemental Form (E2100)
    1. Form No. 1565
ECOG clinical trial administrative data
Description

ECOG clinical trial 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

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C16154
UMLS 2011AA ValueDomain-2
C1704379
Cycle Number (Use '00' for baseline; leave blank if off-treatment or N/A)
Description

CycleNumber

Data type

text

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?
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Nontarget Lesions
Description

Nontarget Lesions

Lesion Number
Description

LesionNumber

Data type

float

Site of Lesion (Multiple nontarget lesions within an organ may be combined as a single site, but must be reported in same manner as at baseline.)
Description

Lesion,AnatomicSite

Data type

text

Site Code (Site codes)
Description

LesionMeasurableEvaluationAnatomicSite

Data type

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property-2
C37894
UMLS 2011AA Property-2
C1513040
Method of Evaluation (Method of Evaluation codes)
Description

MethodofEvaluation

Data type

text

Date of Evaluation (M D Y)
Description

AssessmentDate

Data type

date

Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
Description

Follow-UpStatusofLesions

Data type

text

Unequivocal progressive disease in nontarget lesions is based on: (please describe) (For Site Code 04 effusion/ascites ONLY:)
Description

ProgressiveDiseaseNon-TargetLesionDescriptionText

Data type

text

Alias
NCI Thesaurus ObjectClass
C35571
UMLS 2011AA ObjectClass
C1335499
NCI Thesaurus Property
C3824
UMLS 2011AA Property
C0221198
NCI Thesaurus Property-2
C25592
UMLS 2011AA Property-2
C1518389
NCI Thesaurus Property-3
C25365
UMLS 2011AA Property-3
C0678257
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Cytology Result
Description

CytologyResult

Data type

text

Alias
NCI Thesaurus ObjectClass
C16491
UMLS 2011AA ObjectClass
C0010819
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
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

Date

Data type

text

Ccrr Module For Ecog Nontarget Lesions Supplemental Form (e2100)
Description

Ccrr Module For Ecog Nontarget Lesions Supplemental Form (e2100)

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Similar models

Form No. 1565

1 forms
  1. StudyEvent: ECOG Nontarget Lesions Supplemental Form (E2100)
    1. Form No. 1565
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
ECOG clinical trial administrative data
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain-2)
C1704379 (UMLS 2011AA ValueDomain-2)
CycleNumber
Item
Cycle Number (Use '00' for baseline; leave blank if off-treatment or N/A)
text
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?
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Nontarget Lesions
LesionNumber
Item
Lesion Number
float
Lesion,AnatomicSite
Item
Site of Lesion (Multiple nontarget lesions within an organ may be combined as a single site, but must be reported in same manner as at baseline.)
text
Item
Site Code (Site codes)
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C37894 (NCI Thesaurus Property-2)
C1513040 (UMLS 2011AA Property-2)
CL.3
Code List
Site Code (Site codes)
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Brain (Brain)
C12439 (NCI Thesaurus)
C0006104 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Effusion/ascites (Effusion/Ascites)
CL Item
Gi (GI)
CL Item
Gu (GU)
CL Item
Head & Neck (Head & Neck)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Nodes (Nodes)
CL Item
Skin (Skin)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Other (specify Site) (Other (specify site))
Item
Method of Evaluation (Method of Evaluation codes)
text
CL.4
Code List
Method of Evaluation (Method of Evaluation codes)
CL Item
Clinical Exam (Clinical Exam)
CL Item
Chest X-ray (Chest X-Ray)
CL Item
Ct Scan (CT Scan)
CL Item
Spiral Ct (Spiral CT)
C20645 (NCI Thesaurus)
C0860888 (UMLS 2011AA)
CL Item
Mri (MRI)
CL Item
Ultrasound (Ultrasound)
C64384 (NCI Thesaurus)
C1456803 (UMLS 2011AA)
CL Item
Bone Scan (Bone Scan)
C17646 (NCI Thesaurus)
C0203668 (UMLS 2011AA)
CL Item
Not Evaluated (Not evaluated)
CL Item
Other (specify In Comments) (Other (specify in Comments))
AssessmentDate
Item
Date of Evaluation (M D Y)
date
Item
Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
text
CL.5
Code List
Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
CL Item
Cr (CR)
CL Item
Incompl. Resp./sd (Incompl. resp./SD)
CL Item
Pd (PD)
ProgressiveDiseaseNon-TargetLesionDescriptionText
Item
Unequivocal progressive disease in nontarget lesions is based on: (please describe) (For Site Code 04 effusion/ascites ONLY:)
text
C35571 (NCI Thesaurus ObjectClass)
C1335499 (UMLS 2011AA ObjectClass)
C3824 (NCI Thesaurus Property)
C0221198 (UMLS 2011AA Property)
C25592 (NCI Thesaurus Property-2)
C1518389 (UMLS 2011AA Property-2)
C25365 (NCI Thesaurus Property-3)
C0678257 (UMLS 2011AA Property-3)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Cytology Result
text
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
CL.6
Code List
Cytology Result
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
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)
Date
Item
Date
text
Item Group
Ccrr Module For Ecog Nontarget Lesions Supplemental Form (e2100)
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