ID

1231

Description

GOG Pathology 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=ABA3A314-798F-2466-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3A314-798F-2466-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 6/26/17 6/26/17 - 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 Pathology - GOG Pathology Form - 2059039v3.0

English

FORM F

1 forms  
  1. StudyEvent: GOG Pathology Form
    1. FORM F
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

Primary Disease Assessment
Description

Primary Disease Assessment

Primary site
Description

PrimarySite

Data type

text

Other (Primary Site), specify
Description

PrimarySite,Other

Data type

text

Histologic type (check one)
Description

HistologicType

Data type

text

Other (Histologic Type), specify
Description

HistologicType,OtherName

Data type

text

Histologic grade (Differentiation)
Description

HistologicGrade

Data type

text

Method of evaluation
Description

AssessmentType

Data type

text

Date of evaluation (m d y)
Description

AssessmentDate

Data type

date

ID # of the blocks/slides
Description

SpecimenID

Data type

double

Specimen site
Description

SpecimenSite

Data type

text

Lymph node(s), specify (Specimen Site)
Description

SpecimenSite,LymphNode

Data type

text

Metastatic site, specify (Specimen Site)
Description

SpecimenSite,Metastatic

Data type

text

Other (Specimen Site), specify
Description

SpecimenSite,Other

Data type

text

Secondary Disease Assessment
Description

Secondary Disease Assessment

Method of evaluation
Description

AssessmentMethodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
Date of evaluation (m d y)
Description

AssessmentDate

Data type

date

ID # of the blocks/slides
Description

SpecimenID

Data type

double

Specimen site
Description

SpecimenSite

Data type

text

Lymph node(s), specify (Specimen Site)
Description

SpecimenSite,LymphNode

Data type

text

Metastatic site, specify (Specimen Site)
Description

SpecimenSite,Metastatic

Data type

text

Other (Specimen Site), specify
Description

SpecimenSite,Other

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 Pathology Form
Description

Ccrr Module For Gog Pathology Form

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Similar models

FORM F

1 forms
  1. StudyEvent: GOG Pathology Form
    1. FORM F
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
Primary Disease Assessment
Item
Primary site
text
CL.1
Code List
Primary site
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Endometrium (Endometrium)
C12313 (NCI Thesaurus)
C0014180 (UMLS 2011AA)
CL Item
Fallopian Tube (Fallopian tube)
C12403 (NCI Thesaurus)
C0015560 (UMLS 2011AA)
CL Item
Gestational Trophoblastic Disease (GTD)
CL Item
Ovary (Ovary)
C12404 (NCI Thesaurus)
C0029939 (UMLS 2011AA)
CL Item
Peritoneum (Peritoneum)
C12770 (NCI Thesaurus)
C0031153 (UMLS 2011AA)
CL Item
Uterine Sarcoma (Uterine sarcoma)
CL Item
Vagina (Vagina)
C12407 (NCI Thesaurus)
C0042232 (UMLS 2011AA)
CL Item
Vulva (Vulva)
C12408 (NCI Thesaurus)
C0042993 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
PrimarySite,Other
Item
Other (Primary Site), specify
text
Item
Histologic type (check one)
text
CL.2
Code List
Histologic type (check one)
CL Item
Adenocarcinoma, Unspecified (Adenocarcinoma, type unspecified)
CL Item
Adenocarcinoma With Squamous Differentiation (Adenocarcinoma with squamous differentiation)
CL Item
Adenosquamous (Adenosquamous carcinoma)
CL Item
Clear Cell Carcinoma (Clear cell carcinoma)
CL Item
Endometrioid Adenocarcinoma (Endometrioid adenocarcinoma)
C3769 (NCI Thesaurus)
C0206687 (UMLS 2011AA)
CL Item
Mixed Epithelial Carcinoma, Specify Components (Mixed epithelial tumor)
CL Item
Mucinous Adenocarcinoma (Mucinous adenocarcinoma)
C26712 (NCI Thesaurus)
C0007130 (UMLS 2011AA)
CL Item
Serous Adenocarcinoma (Serous adenocarcinoma)
C40101 (NCI Thesaurus)
C0206701 (UMLS 2011AA)
CL Item
Small Cell Carcinoma (Small cell carcinoma)
C3915 (NCI Thesaurus)
C0262584 (UMLS 2011AA)
CL Item
Squamous Cell Carcinoma (Squamous cell carcinoma, invasive)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
CL Item
Transitional Cell Carcinoma, Including Brenner Tumor (Transitional cell carcinoma)
CL Item
Undifferentiated Carcinoma (Undifferentiated carcinoma)
C3692 (NCI Thesaurus)
C0205698 (UMLS 2011AA)
CL Item
Villoglandular Carcinoma (Villoglandular carcinoma)
CL Item
Carcinosarcoma, homolgous (Carcinosarcoma, homolgous)
CL Item
Carcinosarcoma/mesodermal (mullerian) Mixed Tumor (Carcinosarcoma, heterologous)
CL Item
Endometrial Stromal Sarcoma (Endometrial stromal sarcoma, high grade)
C8973 (NCI Thesaurus)
C0206630 (UMLS 2011AA)
CL Item
Leiomyosarcoma (Leiomyosarcoma)
C3158 (NCI Thesaurus)
C0023269 (UMLS 2011AA)
CL Item
Mucinous Tumor Of Low Malignant Potential (Mucinous tumor of low malignant potential)
CL Item
Serous Tumor Of Low Malignant Potential (Serous tumor of low malignant potential)
CL Item
Mixed serous/mucinous LMP (Mixed serous/mucinous LMP)
CL Item
Granulosa Cell Tumor (Granulosa cell tumor)
C3070 (NCI Thesaurus)
C0018206 (UMLS 2011AA)
CL Item
Sex-cord/stromal, Unclassified (Sex cord stomal tumor, unclassified)
CL Item
Dysgerminoma (Dysgerminoma)
C2996 (NCI Thesaurus)
C0013377 (UMLS 2011AA)
CL Item
Endodermal Sinus Tumor (yolk Sac Tumor) (Endodermal sinus tumor)
CL Item
Germ Cell Tumor, Mixed (Germ cell tumor, mixed)
CL Item
Teratoma, Immature, Specify Components (Teratoma, immature)
CL Item
Teratoma, Mature (Teratoma, mature cystic)
CL Item
Normal Tissue (Normal tissue)
C33177 (NCI Thesaurus)
CL Item
Benign (Benign NOS)
C14172 (NCI Thesaurus)
C0205183 (UMLS 2011AA)
CL Item
Fibroma (Fibroma)
C3041 (NCI Thesaurus)
C0016045 (UMLS 2011AA)
CL Item
Serous Cystadenoma (benign) (Serous cystadenoma)
CL Item
Mucinous Cystadenoma (benign) (Mucinous cystadenoma)
CL Item
Other, Specify (Other, specify)
HistologicType,OtherName
Item
Other (Histologic Type), specify
text
Item
Histologic grade (Differentiation)
text
CL.3
Code List
Histologic grade (Differentiation)
CL Item
Grade 1-well Differentiated (1)
CL Item
Grade 2-moderately Differentiated (2)
CL Item
Grade 3-poorly Differentiated (3)
CL Item
Indeterminate (Indeterminate)
C48658 (NCI Thesaurus)
C0205258 (UMLS 2011AA)
CL Item
Grade Unknown (Unknown)
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
Item
Method of evaluation
text
CL.4
Code List
Method of evaluation
CL Item
Biopsy (Biopsy)
C15189 (NCI Thesaurus)
C0005558 (UMLS 2011AA)
CL Item
Surgery (Surgery)
CL Item
Primary Surgery (Primary surgery)
CL Item
Cytology (Cytology)
C16491 (NCI Thesaurus)
C0010819 (UMLS 2011AA)
CL Item
Staging surgery (Staging surgery)
AssessmentDate
Item
Date of evaluation (m d y)
date
SpecimenID
Item
ID # of the blocks/slides
double
Item
Specimen site
text
CL.7
Code List
Specimen site
CL Item
Bladder Peritoneum (Bladder peritoneum)
CL Item
Bowel Peritoneum/serosa (Bowel peritoneum/serosa)
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Corpus (Corpus)
CL Item
Cul-de-sac (Cul-de-sac)
CL Item
Diaphragm (Diaphragm)
C12702 (NCI Thesaurus)
C0011980 (UMLS 2011AA)
CL Item
Endometrium (Endometrium)
C12313 (NCI Thesaurus)
C0014180 (UMLS 2011AA)
CL Item
Fallopian Tube (Fallopian tube)
C12403 (NCI Thesaurus)
C0015560 (UMLS 2011AA)
CL Item
Omentum (Omentum)
C33209 (NCI Thesaurus)
C0028977 (UMLS 2011AA)
CL Item
Ovary (Ovary)
C12404 (NCI Thesaurus)
C0029939 (UMLS 2011AA)
CL Item
Paracolic Gutter Left (Paracolic gutter left)
CL Item
Paracolic Gutter Right (Paracolic gutter right)
CL Item
Pelvic Wall Left (Pelvic wall left)
CL Item
Pelvic Wall Right (Pelvic wall right)
CL Item
Peritoneum/uterine Serosa (Peritoneum/uterine serosa)
CL Item
Lymph Node(s) (Lymph node(s), specify)
CL Item
Metastatic Site (Metastatic site, specify)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
SpecimenSite,LymphNode
Item
Lymph node(s), specify (Specimen Site)
text
SpecimenSite,Metastatic
Item
Metastatic site, specify (Specimen Site)
text
SpecimenSite,Other
Item
Other (Specimen Site), specify
text
Item Group
Secondary Disease Assessment
Item
Method of evaluation
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
CL.6
Code List
Method of evaluation
CL Item
Cytology (Cytology)
C16491 (NCI Thesaurus)
C0010819 (UMLS 2011AA)
CL Item
Other, Specify (Other, Specify)
CL Item
Surgery (Surgery)
C17173 (NCI Thesaurus)
C0038894 (UMLS 2011AA)
CL Item
Biopsy (Biopsy)
C15189 (NCI Thesaurus)
C0005558 (UMLS 2011AA)
C15189 (NCI Thesaurus)
C0005558 (UMLS 2011AA)
CL Item
Second look (Second look)
CL Item
Primary Gyn Disease Continues To Be Present Following Initial Treatment (Persistence)
CL Item
Recurrence Of Same Gyn Disease Previously Treated Successfully (Recurrence)
AssessmentDate
Item
Date of evaluation (m d y)
date
SpecimenID
Item
ID # of the blocks/slides
double
Item
Specimen site
text
CL.7
Code List
Specimen site
CL Item
Bladder Peritoneum (Bladder peritoneum)
CL Item
Bowel Peritoneum/serosa (Bowel peritoneum/serosa)
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Corpus (Corpus)
CL Item
Cul-de-sac (Cul-de-sac)
CL Item
Diaphragm (Diaphragm)
C12702 (NCI Thesaurus)
C0011980 (UMLS 2011AA)
CL Item
Endometrium (Endometrium)
C12313 (NCI Thesaurus)
C0014180 (UMLS 2011AA)
CL Item
Fallopian Tube (Fallopian tube)
C12403 (NCI Thesaurus)
C0015560 (UMLS 2011AA)
CL Item
Omentum (Omentum)
C33209 (NCI Thesaurus)
C0028977 (UMLS 2011AA)
CL Item
Ovary (Ovary)
C12404 (NCI Thesaurus)
C0029939 (UMLS 2011AA)
CL Item
Paracolic Gutter Left (Paracolic gutter left)
CL Item
Paracolic Gutter Right (Paracolic gutter right)
CL Item
Pelvic Wall Left (Pelvic wall left)
CL Item
Pelvic Wall Right (Pelvic wall right)
CL Item
Peritoneum/uterine Serosa (Peritoneum/uterine serosa)
CL Item
Lymph Node(s) (Lymph node(s), specify)
CL Item
Metastatic Site (Metastatic site, specify)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
SpecimenSite,LymphNode
Item
Lymph node(s), specify (Specimen Site)
text
SpecimenSite,Metastatic
Item
Metastatic site, specify (Specimen Site)
text
SpecimenSite,Other
Item
Other (Specimen Site), specify
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 Pathology Form
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