ID

11925

Descripción

Cycle Dose Drug Form (D2R) GOG-0262 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=

Palabras clave

  1. 18/12/14 18/12/14 - Martin Dugas
  2. 22/8/15 22/8/15 - Martin Dugas
Subido en

22 de agosto de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy

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Cycle Dose Drug Form (D2R) GOG-0262

No Instruction available.

  1. StudyEvent: SE.0000
    1. No Instruction available.
Header Module
Descripción

Header Module

Date form originally completed (m d y)
Descripción

FormOriginalCompleteDate

Tipo de datos

date

Date form amended (m d y)
Descripción

FormAmendedCompleteDate

Tipo de datos

date

Person amending form, last name
Descripción

ResponsiblePersonReportingChangeLastName

Tipo de datos

text

Patient Initials (First, Middle, Last)
Descripción

PatientInitialsName

Tipo de datos

text

Patient Study ID
Descripción

PatientGynecologicOncologyGroupIdentifierNumber

Tipo de datos

text

Person Completing Form, Last Name
Descripción

ResponsiblePersonLastName

Tipo de datos

text

COMMENTS
Descripción

ResearchCommentsText

Tipo de datos

text

Treatment Cycle And Modification
Descripción

Treatment Cycle And Modification

Current Cycle Number
Descripción

TreatmentCurrentCourseNumber

Tipo de datos

float

Cycle Delayed?
Descripción

TreatmentDelayedCycleInd-3

Tipo de datos

boolean

Number of days treatment cycle was delayed
Descripción

TreatmentDelayDayCount

Tipo de datos

float

Cycle delayed reason
Descripción

TreatmentDelayedCycleReason

Tipo de datos

text

Cycle start date (Day 1 m d y)
Descripción

TreatmentCourseBeginDate

Tipo de datos

date

Agent Name
Descripción

Agent Name

Tipo de datos

text

Alias
UMLS CUI [1]
C1521826
Agent Dose level (e.g. mg/m^2)
Descripción

AgentDoseLevelValue

Tipo de datos

text

Were there any dose modifications or additions/omissions to protocol treatment (1=Yes, planned; 2 =Yes, unplanned; 3=No)
Descripción

DoseModificationInd

Tipo de datos

text

Total dose of agents/drugs for this cycle
Descripción

AgentCourseTotalDose

Tipo de datos

float

Units (eg. mg, kg)
Descripción

AgentDoseUOM

Tipo de datos

text

Body weight
Descripción

Body weight

Tipo de datos

float

Unidades de medida
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Body surface area
Descripción

Body surface area

Tipo de datos

float

Unidades de medida
Alias
UMLS CUI [1]
C0005902
ECOG performance status grade
Descripción

ECOG performance status grade

Tipo de datos

integer

Alias
UMLS CUI [1]
C1632812
Pretreatment Hematology And Chemistry Values
Descripción

Pretreatment Hematology And Chemistry Values

Assessment Date (m d y)
Descripción

LesionAssessmentDate

Tipo de datos

date

Hemoglobin
Descripción

Hemoglobin

Tipo de datos

float

Unidades de medida
  • g/dL
Alias
UMLS CUI [1]
C0019046
g/dL
Peripheral Hematocrit Count (1000/L)
Descripción

LaboratoryProcedureErythrocyteResultCount

Tipo de datos

float

WBC
Descripción

WBC

Tipo de datos

float

Unidades de medida
  • /ul
Alias
UMLS CUI [1]
C0023508
/ul
ANC
Descripción

ANC

Tipo de datos

float

Unidades de medida
  • 1000/ul
Alias
UMLS CUI [1]
C0200633
1000/ul
Peripheral Platelet Count
Descripción

Peripheral Platelet Count

Tipo de datos

float

Unidades de medida
  • 1000/uL
Alias
UMLS CUI [1]
C0005821
1000/uL
PT (sec)
Descripción

LaboratoryProcedureProthrombinTimeResultValue

Tipo de datos

float

Unidades de medida
  • seconds
seconds
PTT
Descripción

PTT

Tipo de datos

float

Unidades de medida
  • seconds
Alias
UMLS CUI [1]
C0030605
seconds
BUN
Descripción

BUN

Tipo de datos

float

Unidades de medida
  • mg/dL
Alias
UMLS CUI [1]
C0005845
mg/dL
Creatinine
Descripción

Creatinine

Tipo de datos

float

Unidades de medida
  • mg/dL
Alias
UMLS CUI [1]
C0201976
mg/dL
Creatinine Clearance
Descripción

Creatinine Clearance

Tipo de datos

float

Unidades de medida
  • mL/min
Alias
UMLS CUI [1]
C0373595
mL/min
AST (SGOT)
Descripción

AST (SGOT)

Tipo de datos

float

Unidades de medida
  • U/L
Alias
UMLS CUI [1]
C0201899
U/L
Bilirubin, total
Descripción

Bilirubin, total

Tipo de datos

float

Unidades de medida
  • mg/dL
Alias
UMLS CUI [1]
C0201913
mg/dL
Alkaline Phosphatase
Descripción

Alkaline Phosphatase

Tipo de datos

float

Unidades de medida
  • U/L
Alias
UMLS CUI [1]
C0201850
U/L
Result of CA125 (IU/ml)
Descripción

LaboratoryProcedureCA-125AntigenTumorMarkerResultValue

Tipo de datos

float

INR
Descripción

INR

Tipo de datos

float

Alias
UMLS CUI [1]
C0525032
Other, specify test
Descripción

LaboratoryProcedureSecondOptionalPerformedSpecify

Tipo de datos

text

Other specify value
Descripción

LaboratoryProcedurePerformedValue

Tipo de datos

float

Comments
Descripción

Comments

Similar models

No Instruction available.

  1. StudyEvent: SE.0000
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header Module
FormOriginalCompleteDate
Item
Date form originally completed (m d y)
date
FormAmendedCompleteDate
Item
Date form amended (m d y)
date
ResponsiblePersonReportingChangeLastName
Item
Person amending form, last name
text
PatientInitialsName
Item
Patient Initials (First, Middle, Last)
text
PatientGynecologicOncologyGroupIdentifierNumber
Item
Patient Study ID
text
ResponsiblePersonLastName
Item
Person Completing Form, Last Name
text
ResearchCommentsText
Item
COMMENTS
text
Item Group
Treatment Cycle And Modification
TreatmentCurrentCourseNumber
Item
Current Cycle Number
float
TreatmentDelayedCycleInd-3
Item
Cycle Delayed?
boolean
TreatmentDelayDayCount
Item
Number of days treatment cycle was delayed
float
Item
Cycle delayed reason
text
Code List
Cycle delayed reason
CL Item
Non Protocol Illness (Non protocol illness)
CL Item
Patient Refusal (Patient refusal)
CL Item
Personal Reasons (Personal reasons)
CL Item
Protocol Related Ae (Protocol related AE)
CL Item
Scheduling (Scheduling)
TreatmentCourseBeginDate
Item
Cycle start date (Day 1 m d y)
date
Agent
Item
Agent Name
text
C1521826 (UMLS CUI [1])
AgentDoseLevelValue
Item
Agent Dose level (e.g. mg/m^2)
text
Item
Were there any dose modifications or additions/omissions to protocol treatment (1=Yes, planned; 2 =Yes, unplanned; 3=No)
text
Code List
Were there any dose modifications or additions/omissions to protocol treatment (1=Yes, planned; 2 =Yes, unplanned; 3=No)
CL Item
Yes, Planned (i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)
CL Item
Yes, Unplanned (i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
CL Item
No (No)
AgentCourseTotalDose
Item
Total dose of agents/drugs for this cycle
float
AgentDoseUOM
Item
Units (eg. mg, kg)
text
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
BSA
Item
Body surface area
float
C0005902 (UMLS CUI [1])
Item
ECOG performance status grade
integer
C1632812 (UMLS CUI [1])
Code List
ECOG performance status grade
CL Item
Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0) (0)
CL Item
Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1) (1)
CL Item
Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2) (2)
CL Item
Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3) (3)
CL Item
Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4) (4)
CL Item
Dead (5) (5)
Item Group
Pretreatment Hematology And Chemistry Values
LesionAssessmentDate
Item
Assessment Date (m d y)
date
Hemoglobin
Item
Hemoglobin
float
C0019046 (UMLS CUI [1])
LaboratoryProcedureErythrocyteResultCount
Item
Peripheral Hematocrit Count (1000/L)
float
Leukocytes (WBC)
Item
WBC
float
C0023508 (UMLS CUI [1])
Neutrophil count
Item
ANC
float
C0200633 (UMLS CUI [1])
Platelets
Item
Peripheral Platelet Count
float
C0005821 (UMLS CUI [1])
LaboratoryProcedureProthrombinTimeResultValue
Item
PT (sec)
float
PTT
Item
PTT
float
C0030605 (UMLS CUI [1])
BUN
Item
BUN
float
C0005845 (UMLS CUI [1])
Creatinine, Serum
Item
Creatinine
float
C0201976 (UMLS CUI [1])
Creatinine Clearance
Item
Creatinine Clearance
float
C0373595 (UMLS CUI [1])
AST
Item
AST (SGOT)
float
C0201899 (UMLS CUI [1])
Bilirubin, total
Item
Bilirubin, total
float
C0201913 (UMLS CUI [1])
Alkaline Phosphatase
Item
Alkaline Phosphatase
float
C0201850 (UMLS CUI [1])
LaboratoryProcedureCA-125AntigenTumorMarkerResultValue
Item
Result of CA125 (IU/ml)
float
INR
Item
INR
float
C0525032 (UMLS CUI [1])
LaboratoryProcedureSecondOptionalPerformedSpecify
Item
Other, specify test
text
LaboratoryProcedurePerformedValue
Item
Other specify value
float
Item Group
Comments

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