ID

1199

Beschrijving

GOG Treatment Completion Form Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3ADBB-5221-246F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3ADBB-5221-246F-E034-0003BA12F5E7

Trefwoorden

Versies (2)
  1. 27-08-12 27-08-12 -
  2. 24-06-17 24-06-17 - Martin Dugas
Geüploaded op

27 augustus 2012

DOI

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Licentie

Creative Commons BY-NC 3.0
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Cervical Cancer NCT00064077 Treatment - GOG Treatment Completion Form - 2059221v3.0

Engels

FORM Q0

1 Formulieren  
  1. StudyEvent: GOG Treatment Completion Form
    1. FORM Q0
Header Module
Beschrijving

Header Module

Date form originally completed (m d y)
Beschrijving

FormCompletionDate,Original

Datatype

date

Date form amended (m d y)
Beschrijving

FormCompletionDate,Amended

Datatype

date

Person amending form, last name
Beschrijving

ResponsiblePersonReportingChangeLastName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Name, Last
Beschrijving

PatientName,Last

Datatype

text

Patient Name, First
Beschrijving

PatientName,First

Datatype

text

Patient Study ID
Beschrijving

PatientStudyID

Datatype

text

Person Completing Form, Last Name
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Treatment Schedule
Beschrijving

Treatment Schedule

Total number of cycles given
Beschrijving

TotalCourseNumber

Datatype

double

Last date (any modality of) protocol therapy was given (m d y)
Beschrijving

TreatmentEndDate

Datatype

date

Off-treatment Reason
Beschrijving

Off-treatment Reason

Reason treatment ended (check only one)
Beschrijving

OffTreatmentReason

Datatype

text

Specify toxicity (unnamed)
Beschrijving

OffTreatmentReason,Toxicity

Datatype

text

Specify reason (unnamed)
Beschrijving

ReasonOff-TreatmentWithdrawalPatientSpecify

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25638
UMLS 2011AA ObjectClass
C0392360
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Metathesaurus Property
C0030705
NCI Thesaurus Property
C41341
UMLS 2011AA Property
C2825032
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Specify disease (unnamed)
Beschrijving

OffTreatmentReason,ComplicatingDisease

Datatype

text

Other, specify (Off Treatment Reason)
Beschrijving

OffTreatmentReason,Other

Datatype

text

Will patient receive further treatment?
Beschrijving

FurtherTreatmentInd

Datatype

text

Specify further treatment (unnamed)
Beschrijving

FurtherTreatmentSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C25519
UMLS 2011AA ObjectClass
C1517331
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Comments
Beschrijving

Comments

COMMENTS
Beschrijving

Comments

Datatype

text

Footer Module
Beschrijving

Footer Module

Participating Group Code
Beschrijving

ParticipatingGroupCode

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Participating Group Protocol Number
Beschrijving

ParticipatingGroupProtocolNumber

Datatype

double

Participating Patient Study ID
Beschrijving

PatientParticipatingIdentifierNumber

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Ccrr Module For Gog Treatment Completion Form
Beschrijving

Ccrr Module For Gog Treatment Completion Form

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Similar models

FORM Q0

1 Formulieren
  1. StudyEvent: GOG Treatment Completion Form
    1. FORM Q0
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header Module
FormCompletionDate,Original
Item
Date form originally completed (m d y)
date
FormCompletionDate,Amended
Item
Date form amended (m d y)
date
ResponsiblePersonReportingChangeLastName
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
PatientStudyID
Item
Patient Study ID
text
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
Item Group
Treatment Schedule
TotalCourseNumber
Item
Total number of cycles given
double
TreatmentEndDate
Item
Last date (any modality of) protocol therapy was given (m d y)
date
Item Group
Off-treatment Reason
Item
Reason treatment ended (check only one)
text
CL.1
Code List
Reason treatment ended (check only one)
CL Item
Routine Completion Of Planned Protocol Treatment (Routine completion of planned protocol treatment)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Toxicity/side Effects/complications (Toxicity/side effects/complications)
CL Item
Patient Withdrawal Or Refusal For Reason Other Than Toxicity (Patient withdrawal or refusal for reason other than toxicity)
CL Item
Death Of Patient Occurred After The Patient Began Protocol Therapy (Death after beginning protocol therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
OffTreatmentReason,Toxicity
Item
Specify toxicity (unnamed)
text
ReasonOff-TreatmentWithdrawalPatientSpecify
Item
Specify reason (unnamed)
text
C25638 (NCI Thesaurus ObjectClass)
C0392360 (UMLS 2011AA ObjectClass)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C0030705 (NCI Metathesaurus Property)
C41341 (NCI Thesaurus Property)
C2825032 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
OffTreatmentReason,ComplicatingDisease
Item
Specify disease (unnamed)
text
OffTreatmentReason,Other
Item
Other, specify (Off Treatment Reason)
text
Item
Will patient receive further treatment?
text
CL.2
Code List
Will patient receive further treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
FurtherTreatmentSpecify
Item
Specify further treatment (unnamed)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25519 (NCI Thesaurus ObjectClass)
C1517331 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Footer Module
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
ParticipatingGroupProtocolNumber
Item
Participating Group Protocol Number
double
PatientParticipatingIdentifierNumber
Item
Participating Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Ccrr Module For Gog Treatment Completion Form
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