ID

1264

Beschrijving

SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227) S0227 Comparison of Cisplatin Combined With Either Paclitaxel or Gemcitabine in Treating Patients With Recurrent, Persistent, or Metastatic Cervical Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C447B6-E4F0-3A7F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C447B6-E4F0-3A7F-E034-0003BA12F5E7

Trefwoorden

Versies (3)
  1. 27-08-12 27-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 03-07-15 03-07-15 -
Geüploaded op

27 augustus 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Cervical Cancer NCT00057928 Follow-Up - SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227) - 2057161v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227)
    1. No Instruction available.
Unnamed1
Beschrijving

Unnamed1

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F M)
Beschrijving

PatientInitialsName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Reporting Period Start Date (Date off protocol for the first follow-up form; last report period end date otherwise)
Beschrijving

IntervalReportFromDate

Datatype

date

Institution / Affiliate
Beschrijving

InstitutionName

Datatype

text

Physician (Groups other than SWOG)
Beschrijving

RegisteredInvestigator

Datatype

text

Group Name
Beschrijving

ParticipatingGroupName

Datatype

text

Study No.
Beschrijving

Particip.GroupProtocolNumber

Datatype

double

Pt. ID
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Unnamed2
Beschrijving

Unnamed2

Reporting Period End Date (Date of completion of the current form.)
Beschrijving

IntervalReportToDate

Datatype

date

Vital Status
Beschrijving

Vital Status

Vital Status
Beschrijving

VitalStatus

Datatype

text

Alias
NCI Thesaurus Property
C25717
UMLS 2011AA Property
C1148433
Date of last contact or death
Beschrijving

DeathDate/LastContactDate

Datatype

date

Disease Follow Up Status
Beschrijving

Disease Follow Up Status

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Beschrijving

Hasthepatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?

Datatype

text

Date of Last Clinical Assessment (If Yes)
Beschrijving

CancerFollow-upStatusDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of First Relapse Or Progression
Beschrijving

Notice Of First Relapse Or Progression

Has the patient developed a first protocol defined relapse or progression that has not been previously reported
Beschrijving

Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?

Datatype

text

Date of progression/relapse
Beschrijving

ProgressionDate,First

Datatype

date

Site
Beschrijving

ProgressionSite

Datatype

text

Notice Of New Primary
Beschrijving

Notice Of New Primary

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

NewPrimaryCancerInd

Datatype

text

Date of Diagnosis (If Yes)
Beschrijving

NewPrimaryCancerDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site
Beschrijving

NewPrimarySite

Datatype

text

Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

Non-protocol Treatment
Beschrijving

Non-protocol Treatment

Has the patient received any (non-protocol) cancer treatment in this reporting period
Beschrijving

ConcurrentNon-ProtocolTherapyInd

Datatype

text

Non-Protocol Surgery (If Yes, complete the following)
Beschrijving

Non-protocolSurgeryPerformedInd-3

Datatype

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
Non-Protocol Chemotherapy (if yes, Treatment Start Date)
Beschrijving

Non-ProtocolChemotherapyInd

Datatype

text

Non-Protocol Hormonal Therapy (if yes, Treatment Start Date)
Beschrijving

Non-ProtocolHormonalTherapyInd

Datatype

text

Non-Protocol Immunotherapy (if yes, Treatment Start Date)
Beschrijving

Non-ProtocolImmunotherapyInd

Datatype

text

Non-Protocol Radiation Therapy (if yes, Treatment Start Date)
Beschrijving

Non-ProtocolRTInd

Datatype

text

Other Non-Protocol Therapy (if yes, Treatment Start Date)
Beschrijving

OtherNon-ProtocolTherapyInd

Datatype

text

Yes, specify
Beschrijving

Non-ProtocolTherapyType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass
C2167
UMLS 2011AA ObjectClass
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Yes, specify
Beschrijving

Non-ProtocolTherapyType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass
C2167
UMLS 2011AA ObjectClass
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Long Term Toxicity
Beschrijving

Long Term Toxicity

Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade >= 3) long term toxicity that has not been previously reported?
Beschrijving

LateAdverseEventInd

Datatype

text

Neuropathy-motor
Beschrijving

Neuropathy-motor

Datatype

text

Neuropathy-sensory
Beschrijving

Neuropathy-sensory

Datatype

text

Grade
Beschrijving

Grade

Datatype

text

Grade
Beschrijving

Grade

Datatype

text

Other (specify Toxicities and Grades)
Beschrijving

OtherInd-3

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

Ccrr Module For Southwest Oncology Group S0227 Follow Up Form (s0227)
Beschrijving

Ccrr Module For Southwest Oncology Group S0227 Follow Up Form (s0227)

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 FOLLOW UP FORM (S0227)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitialsName
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
IntervalReportFromDate
Item
Reporting Period Start Date (Date off protocol for the first follow-up form; last report period end date otherwise)
date
InstitutionName
Item
Institution / Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
ParticipatingGroupName
Item
Group Name
text
Particip.GroupProtocolNumber
Item
Study No.
double
PatientStudyID,ParticipatingGroup
Item
Pt. ID
text
Item Group
Unnamed2
IntervalReportToDate
Item
Reporting Period End Date (Date of completion of the current form.)
date
Item Group
Vital Status
Item
Vital Status
text
C25717 (NCI Thesaurus Property)
C1148433 (UMLS 2011AA Property)
CL.1
Code List
Vital Status
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death
date
Item Group
Disease Follow Up Status
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
text
CL.2
Code List
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
CL Item
No2005605 (No)
CL Item
Yes2005606 (Yes)
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment (If Yes)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Notice Of First Relapse Or Progression
Item
Has the patient developed a first protocol defined relapse or progression that has not been previously reported
text
CL.3
Code List
Has the patient developed a first protocol defined relapse or progression that has not been previously reported
CL Item
No2007229 (No)
CL Item
Yes2007230 (Yes)
ProgressionDate,First
Item
Date of progression/relapse
date
ProgressionSite
Item
Site
text
Item Group
Notice Of New Primary
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
text
CL.4
Code List
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed 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)
NewPrimaryCancerDate
Item
Date of Diagnosis (If Yes)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Non-protocol Treatment
Item
Has the patient received any (non-protocol) cancer treatment in this reporting period
text
CL.5
Code List
Has the patient received any (non-protocol) cancer treatment in this reporting period
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Surgery (If Yes, complete the following)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
CL.6
Code List
Non-Protocol Surgery (If Yes, complete the following)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Chemotherapy (if yes, Treatment Start Date)
text
CL.7
Code List
Non-Protocol Chemotherapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Hormonal Therapy (if yes, Treatment Start Date)
text
CL.8
Code List
Non-Protocol Hormonal Therapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Immunotherapy (if yes, Treatment Start Date)
text
CL.9
Code List
Non-Protocol Immunotherapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Radiation Therapy (if yes, Treatment Start Date)
text
CL.10
Code List
Non-Protocol Radiation Therapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Other Non-Protocol Therapy (if yes, Treatment Start Date)
text
CL.11
Code List
Other Non-Protocol Therapy (if yes, Treatment Start Date)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolTherapyType
Item
Yes, specify
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass)
C1443775 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Non-ProtocolTherapyType
Item
Yes, specify
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass)
C1443775 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item Group
Long Term Toxicity
Item
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade >= 3) long term toxicity that has not been previously reported?
text
CL.12
Code List
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) 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)
Item
Neuropathy-motor
text
CL.13
Code List
Neuropathy-motor
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Neuropathy-sensory
text
CL.14
Code List
Neuropathy-sensory
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Grade
Item
Grade
text
Grade
Item
Grade
text
OtherInd-3
Item
Other (specify Toxicities and Grades)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group S0227 Follow Up Form (s0227)
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