ID

1228

Description

GOG Follow-Up 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=ABA3B911-E14B-2476-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3B911-E14B-2476-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 6/25/17 6/25/17 - Martin Dugas
Uploaded on

August 27, 2012

DOI

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License

Creative Commons BY-NC 3.0
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Cervical Cancer NCT00064077 Follow-Up - GOG Follow-Up Form - 2059334v3.0

English

FORM Q

1 forms  
  1. StudyEvent: GOG Follow-Up Form
    1. FORM Q
Header Module
Description

Header Module

Date form originally completed (m d y)
Description

FormCompletionDate,Original

Data type

date

Date form amended (m d y)
Description

FormCompletionDate,Amended

Data type

date

Person amending form, last name
Description

ResponsiblePersonReportingChangeLastName

Data type

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
Description

PatientName,Last

Data type

text

Patient Name, First
Description

PatientName,First

Data type

text

Patient Study ID
Description

PatientStudyID

Data type

text

Person Completing Form, Last Name
Description

PersonCompletingForm,LastName

Data type

text

Vital Status
Description

Vital Status

Patient's vital status
Description

Patient'sVitalStatus

Data type

text

Primary cause of death
Description

DeathReason

Data type

text

Death due to other cause (specify)
Description

DeathReason,Specify

Data type

text

Death due to other cause (specify)
Description

DeathReason,Specify

Data type

text

Death date / last contact date (m d y)
Description

DeathDate/LastContactDate

Data type

date

Was patient unable to be contacted for current scheduled follow-up?
Description

LosttoFollow-UpInd

Data type

text

Notice Of Progression
Description

Notice Of Progression

Has the patient been diagnosed with a new progression?
Description

NewProgressionInd

Data type

text

Date of progression (recurrence m d y)
Description

ProgressionDate

Data type

date

Site(s) of progression
Description

ProgressionSite

Data type

text

What was the method used to determine progression?
Description

ProgressionAssessmentMethod

Data type

text

Ca125 And Other Biomarkers
Description

Ca125 And Other Biomarkers

Marker 2 (Marker names & values)
Description

MarkerName

Data type

text

Marker 2 (Marker names & values)
Description

MarkerName

Data type

text

Marker 2 Value
Description

TumorMarkerAssessmentValue

Data type

double

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C17220
UMLS 2011AA ObjectClass
C0041365
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
Marker 2 Value
Description

TumorMarkerAssessmentValue

Data type

double

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C17220
UMLS 2011AA ObjectClass
C0041365
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
Date of CA125 (s or other biomarkers Please provide dates of the measurements corresponding to the values given. m d y)
Description

TumorMarker,CA125Date

Data type

date

Notice Of New Primary
Description

Notice Of New Primary

Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
Description

NewPrimaryCancerInd

Data type

text

Date of diagnosis (m d y)
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Site(s) of new primary
Description

NewPrimarySite

Data type

text

Late Adverse Event
Description

Late Adverse Event

Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >/= 3), long term toxicity that has not been previously reported?
Description

LateAdverseEventInd

Data type

text

Adverse event term
Description

LateAdverseEventTerm

Data type

text

Late adverse event grade
Description

LateAdverseEventGrade

Data type

text

Late Adverse Event Onset Date (m d y)
Description

LateAdverseEventOnsetDate

Data type

date

CTC adverse event attribution (*Adverse Event Attribution Codes 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
Description

CTCAdverseEventAttributionCode

Data type

text

Non-protocol Therapy
Description

Non-protocol Therapy

Is the patient receiving any non-protocol cancer therapy not previously reported?
Description

Non-ProtocolTherapyInd

Data type

text

Name of other non-protocol therapy
Description

OtherNon-ProtocolTherapyName

Data type

text

Date of first non-protocol therapy (m d y)
Description

Non-ProtocolTherapyDate,First

Data type

date

Additional therapy reason
Description

AdditionalTherapyReason

Data type

text

Comments
Description

Comments

COMMENTS
Description

Comments

Data type

text

Footer Module
Description

Footer Module

Participating Group Code
Description

ParticipatingGroupCode

Data type

text

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

ParticipatingGroupProtocolNumber

Data type

double

Participating Patient Study ID
Description

PatientParticipatingIdentifierNumber

Data type

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 Follow-up Form
Description

Ccrr Module For Gog Follow-up Form

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Similar models

FORM Q

1 forms
  1. StudyEvent: GOG Follow-Up Form
    1. FORM Q
Name
Type
Description | Question | Decode (Coded Value)
Data type
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
Vital Status
Item
Patient's vital status
text
CL.1
Code List
Patient's vital status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item
Primary cause of death
text
CL.2
Code List
Primary cause of death
CL Item
Due To This Disease (Due to this disease)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To Other Cause (Due to other cause)
DeathReason,Specify
Item
Death due to other cause (specify)
text
DeathReason,Specify
Item
Death due to other cause (specify)
text
DeathDate/LastContactDate
Item
Death date / last contact date (m d y)
date
Item
Was patient unable to be contacted for current scheduled follow-up?
text
CL.3
Code List
Was patient unable to be contacted for current scheduled follow-up?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Notice Of Progression
Item
Has the patient been diagnosed with a new progression?
text
CL.4
Code List
Has the patient been diagnosed with a new progression?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate
Item
Date of progression (recurrence m d y)
date
ProgressionSite
Item
Site(s) of progression
text
Item
What was the method used to determine progression?
text
CL.5
Code List
What was the method used to determine progression?
CL Item
Histology (Histologic)
C16681 (NCI Thesaurus)
C0019638 (UMLS 2011AA)
CL Item
Radiographic (Radiologic)
CL Item
Physical Exam (Physical exam)
CL Item
Tumor Markers (Tumor marker)
Item Group
Ca125 And Other Biomarkers
MarkerName
Item
Marker 2 (Marker names & values)
text
MarkerName
Item
Marker 2 (Marker names & values)
text
TumorMarkerAssessmentValue
Item
Marker 2 Value
double
C25367 (NCI Thesaurus Property)
C17220 (NCI Thesaurus ObjectClass)
C0041365 (UMLS 2011AA ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
TumorMarkerAssessmentValue
Item
Marker 2 Value
double
C25367 (NCI Thesaurus Property)
C17220 (NCI Thesaurus ObjectClass)
C0041365 (UMLS 2011AA ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
TumorMarker,CA125Date
Item
Date of CA125 (s or other biomarkers Please provide dates of the measurements corresponding to the values given. m d y)
date
Item Group
Notice Of New Primary
Item
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
text
CL.6
Code List
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimaryCancerDate
Item
Date of diagnosis (m d y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
Site(s) of new primary
text
Item Group
Late Adverse Event
Item
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >/= 3), long term toxicity that has not been previously reported?
text
CL.7
Code List
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >/= 3), long term toxicity that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
LateAdverseEventTerm
Item
Adverse event term
text
LateAdverseEventGrade
Item
Late adverse event grade
text
LateAdverseEventOnsetDate
Item
Late Adverse Event Onset Date (m d y)
date
Item
CTC adverse event attribution (*Adverse Event Attribution Codes 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
text
CL.8
Code List
CTC adverse event attribution (*Adverse Event Attribution Codes 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
CL Item
Unrelated (Unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (Unlikely)
CL Item
Possibly (Possibly)
CL Item
Probably (Probably)
CL Item
Definitely (Definitely)
Item Group
Non-protocol Therapy
Item
Is the patient receiving any non-protocol cancer therapy not previously reported?
text
CL.9
Code List
Is the patient receiving any non-protocol cancer therapy not previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
OtherNon-ProtocolTherapyName
Item
Name of other non-protocol therapy
text
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy (m d y)
date
AdditionalTherapyReason
Item
Additional therapy reason
text
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 Follow-up Form
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