0 Beoordelingen

ID

11841

Beschrijving

E1505 Hypertension Status Form Chemotherapy With or Without Bevacizumab in Treating Patients With Stage IB, Stage II, or Stage IIIA Non-Small Lung Cancer That Was Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1C55F49C-6CD4-6958-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1C55F49C-6CD4-6958-E044-0003BA3F9857

Trefwoorden

  1. 19-09-12 19-09-12 -
  2. 08-08-14 08-08-14 - Martin Dugas
  3. 16-12-14 16-12-14 - Martin Dugas
  4. 09-01-15 09-01-15 - Martin Dugas
  5. 07-08-15 07-08-15 - Martin Dugas
Geüploaded op

7 augustus 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy

Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Itemgroep Commentaren voor :

Item Commentaren voor :


    Geen commentaren

    U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

    Hypertension Status Form Lung Cancer E1505 NCT00324805

    INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

    General information
    Beschrijving

    General information

    Alias
    UMLS CUI-1
    C1508263
    ECOG Protocol Number
    Beschrijving

    Protocol Number ECOG

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    ECOG Patient ID
    Beschrijving

    Patient ID ECOG

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    DCI Name
    Beschrijving

    Generic drug form

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C3242750
    NCI Thesaurus Property
    C19464
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus ObjectClass-2
    C25452
    Registration Step
    Beschrijving

    Registration Number

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1514821
    NCI Thesaurus ObjectClass
    C25646
    UMLS CUI-2
    C0237753
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    Patient Initials (Last, First)
    Beschrijving

    Patient Initials

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Participating Group Protocol Number
    Beschrijving

    Study Number Participating Group

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Institution/Affiliate
    Beschrijving

    Institution Name

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Participating Group Patient ID
    Beschrijving

    Trial subject ID Participating Group

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Please mark an 'X' if data have been amended. (Please circle amended items in red)
    Beschrijving

    Data amended

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Date data amended (M D Y)
    Beschrijving

    Data amended date

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    UMLS CUI-2
    C0011008
    NCI Thesaurus Property
    C25416
    NCI Thesaurus ValueDomain-2
    C25367
    Reporting Period
    Beschrijving

    Reporting Period

    Systolic
    Beschrijving

    Systolic

    Datatype

    integer

    Maateenheden
    • mmHg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    NCI Thesaurus Property
    C25214
    NCI Thesaurus ObjectClass
    C25298
    UMLS CUI [1]
    C0871470
    mmHg
    Diastolic
    Beschrijving

    Diastolic

    Datatype

    integer

    Maateenheden
    • mmHg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    NCI Thesaurus Property
    C25214
    NCI Thesaurus ObjectClass
    C25299
    UMLS CUI [1]
    C0428883
    mmHg
    Mark an 'X' if not done (during this reporting period)
    Beschrijving

    Laboratory Procedure Not Performed

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0022885
    NCI Thesaurus Property
    C25594
    UMLS CUI-2
    C0445106
    NCI Thesaurus Property-2
    C38000
    NCI Thesaurus ObjectClass
    C25294
    Date of Assessment (most recent)
    Beschrijving

    Assessment Date

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2985720
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C38000
    Anti-Hypertensive Drugs
    Beschrijving

    Anti-Hypertensive Drugs

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    NCI Thesaurus ObjectClass
    C270
    NCI Thesaurus ObjectClass-2
    C25730
    NCI Thesaurus Property
    C25382
    UMLS CUI [1]
    C0003364
    Other, specify
    Beschrijving

    Other, specify

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    NCI Thesaurus ObjectClass
    C270
    NCI Thesaurus ObjectClass-2
    C25730
    NCI Thesaurus Property
    C25382
    UMLS CUI [1]
    C0003364
    Reporting Period
    Beschrijving

    Clinical Trial Period

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C2347804
    NCI Thesaurus ObjectClass
    C25214
    NCI Thesaurus Property
    C25616
    NCI Thesaurus ObjectClass-2
    C25651
    Off Treatment Report Period
    Beschrijving

    PersonOff-TreatmentTimePeriodType

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus Property-2
    C25601
    UMLS 2011AA Property-2
    C1518544
    NCI Thesaurus Property-3
    C25207
    UMLS 2011AA Property-3
    C0040223
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Comments
    Beschrijving

    Comments

    Investigator Signature
    Beschrijving

    Investigator Signature

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    NCI Thesaurus ObjectClass
    C17089
    Investigator Signature Date
    Beschrijving

    Investigator Signature Date

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    UMLS CUI-2
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C17089

    Similar models

    INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    General information
    C1508263 (UMLS CUI-1)
    Protocol Number ECOG
    Item
    ECOG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Patient ID ECOG
    Item
    ECOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Generic drug form
    Item
    DCI Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C3242750 (UMLS CUI-1)
    C19464 (NCI Thesaurus Property)
    C25474 (NCI Thesaurus ObjectClass)
    C25452 (NCI Thesaurus ObjectClass-2)
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1514821 (UMLS CUI-1)
    C25646 (NCI Thesaurus ObjectClass)
    C0237753 (UMLS CUI-2)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    Patient Initials
    Item
    Patient Initials (Last, First)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Participating Group Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Data amended
    Item
    Please mark an 'X' if data have been amended. (Please circle amended items in red)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Data amended date
    Item
    Date data amended (M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C0011008 (UMLS CUI-2)
    C25416 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item Group
    Reporting Period
    Systolic blood pressure
    Item
    Systolic
    integer
    C25209 (NCI Thesaurus ValueDomain)
    C25214 (NCI Thesaurus Property)
    C25298 (NCI Thesaurus ObjectClass)
    C0871470 (UMLS CUI [1])
    Diastolic blood pressure
    Item
    Diastolic
    integer
    C25209 (NCI Thesaurus ValueDomain)
    C25214 (NCI Thesaurus Property)
    C25299 (NCI Thesaurus ObjectClass)
    C0428883 (UMLS CUI [1])
    Laboratory Procedure Not Performed
    Item
    Mark an 'X' if not done (during this reporting period)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0022885 (UMLS CUI-1)
    C25594 (NCI Thesaurus Property)
    C0445106 (UMLS CUI-2)
    C38000 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    Assessment Date
    Item
    Date of Assessment (most recent)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2985720 (UMLS CUI-1)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C38000 (NCI Thesaurus Property)
    Item
    Anti-Hypertensive Drugs
    text
    C25284 (NCI Thesaurus ValueDomain)
    C270 (NCI Thesaurus ObjectClass)
    C25730 (NCI Thesaurus ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C0003364 (UMLS CUI [1])
    Code List
    Anti-Hypertensive Drugs
    CL Item
    No Medication Given (No medication given)
    C0013227 (UMLS CUI-1)
    C0332197 (UMLS CUI-2)
    CL Item
    Beta Blocker (Beta blockers)
    C0001645 (UMLS CUI-1)
    CL Item
    Diuretic (Diuretics)
    C0012798 (UMLS CUI-1)
    CL Item
    Calcium Channel Blocker (Calcium channel blockers)
    C0006684 (UMLS CUI-1)
    CL Item
    Angiotensin II Receptor Blocker (Angiotensin II inhibitors)
    C0521942 (UMLS CUI-1)
    CL Item
    ACE Inhibitor (ACE inhibitors)
    C0003015 (UMLS CUI-1)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS CUI-1)
    Antihypertensive Agents
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C270 (NCI Thesaurus ObjectClass)
    C25730 (NCI Thesaurus ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C0003364 (UMLS CUI [1])
    Item
    Reporting Period
    text
    C25284 (NCI Thesaurus ValueDomain)
    C2347804 (UMLS CUI-1)
    C25214 (NCI Thesaurus ObjectClass)
    C25616 (NCI Thesaurus Property)
    C25651 (NCI Thesaurus ObjectClass-2)
    Code List
    Reporting Period
    CL Item
    Baseline (Baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    CL Item
    Cycle 1 (Cycle 1)
    CL Item
    Cycle 10 (Cycle 10)
    CL Item
    Cycle 11 (Cycle 11)
    CL Item
    Cycle 12 (Cycle 12)
    CL Item
    Cycle 13 (Cycle 13)
    CL Item
    Cycle 14 (Cycle 14)
    CL Item
    Cycle 15 (Cycle 15)
    CL Item
    Cycle 16 (Cycle 16)
    CL Item
    Cycle 17 (Cycle 17)
    CL Item
    Cycle 2 (Cycle 2)
    CL Item
    Cycle 3 (Cycle 3)
    CL Item
    Cycle 4 (Cycle 4)
    CL Item
    Cycle 5 (Cycle 5)
    CL Item
    Cycle 6 (Cycle 6)
    CL Item
    Cycle 7 (Cycle 7)
    CL Item
    Cycle 8 (Cycle 8)
    CL Item
    Cycle 9 (Cycle 9)
    Item
    Off Treatment Report Period
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25601 (NCI Thesaurus Property-2)
    C1518544 (UMLS 2011AA Property-2)
    C25207 (NCI Thesaurus Property-3)
    C0040223 (UMLS 2011AA Property-3)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Off Treatment Report Period
    CL Item
    3 Months Post-treatment (3 Months Post-Treatment)
    CL Item
    6 Months Post-treatment (6 Months Post-Treatment)
    CL Item
    9 Months Post-treatment (9 Months Post-Treatment)
    CL Item
    12 Months Post-treatment (12 Months Post-Treatment)
    Item Group
    Comments
    Investigator Signature
    Item
    Investigator Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    Investigator Signature Date
    Item
    Investigator Signature Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C0011008 (UMLS CUI-2)
    C25367 (NCI Thesaurus ValueDomain-2)
    C17089 (NCI Thesaurus ObjectClass)

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial