ID

1287

Description

GOG Common Toxicity Reporting 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=ABA3B3D1-8528-2473-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3B3D1-8528-2473-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

August 27, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Cervical Cancer NCT00064077 Toxicity - GOG Common Toxicity Reporting Form - 2059265v3.0

English

FORM T

1 forms  
  1. StudyEvent: GOG Common Toxicity Reporting Form
    1. FORM T
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

Adverse Events - Section 1
Description

Adverse Events - Section 1

Current course number (The toxicities listed below occurred following this course of therapy)
Description

CurrentCourseNumber

Data type

double

Has the patient received any transfusions during this course of therapy?
Description

TransfusionInd

Data type

text

Was patient hospitalized as a result of reported adverse events?
Description

InpatientHospitalizationInd

Data type

text

Were cytokines administered this course?
Description

AgentCytokineAdministeredInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C20464
UMLS 2011AA Property
C0079189
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Yes (Cytokines), specify
Description

AgentCytokineAdministeredSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C20464
UMLS 2011AA Property
C0079189
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Has an Adverse Drug Reaction Report been filed?
Description

ADRFiledInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25410
UMLS 2011AA ObjectClass
C1521800
NCI Thesaurus Property
C25175
UMLS 2011AA Property
C1522646
Adverse Events - Section 2
Description

Adverse Events - Section 2

Peripheral WBC count, Done
Description

LaboratoryProcedureLeukocyteResultInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C12529
UMLS 2011AA Property
C0023516
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
Peripheral WBC count (1000/mm3 Nadir)
Description

Lab,Hematology,WBC

Data type

double

Peripheral WBC count, Date (m d y)
Description

Lab,Hematology,WBCDate

Data type

date

Peripheral Granulocytes count, Done
Description

LaboratoryProcedureAbsoluteNeutrophilCountGranulocyteOutcomeInd-3

Data type

text

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property
C12530
UMLS 2011AA Property
C0018183
NCI Thesaurus Property
C63321
UMLS 2011AA Property
C0948762
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Peripheral Granulocytes count (ANC, 1000/mm3 Nadir)
Description

Lab,Hematology,GranulocyteCount

Data type

double

Peripheral Granulocytes count, Date
Description

Lab,Hematology,GranDate

Data type

date

Peripheral Platelet count, Done
Description

LaboratoryProcedurePlateletResultInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property
C12520
UMLS 2011AA Property
C0005821
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
Peripheral Platelet count (mm3 Nadir)
Description

Lab,Hematology,Platelets

Data type

double

Peripheral Platelet count, Date
Description

Lab,Hematology,PlateletDate

Data type

date

Hemoglobin, Done
Description

LaboratoryProcedureHemoglobinResultInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C16676
UMLS 2011AA Property
C0019046
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
Hemoglobin (G/DL Nadir)
Description

Lab,Hematology,Hemoglobin

Data type

double

Hemoglobin, Date
Description

Lab,Hematology,HGBDate

Data type

date

CTC Adverse Event Grade
Description

CTCAdverseEventGrade

Data type

text

CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
Description

CTCAdverseEventAttributionCode

Data type

text

Adverse Events - Section 3
Description

Adverse Events - Section 3

CTC Adverse Event Term
Description

CTCAdverseEventTerm

Data type

text

CTC Adverse Event Grade
Description

CTCAdverseEventGrade

Data type

text

CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
Description

CTCAdverseEventAttributionCode

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 Common Toxicity Reporting Form
Description

Ccrr Module For Gog Common Toxicity Reporting Form

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Similar models

FORM T

1 forms
  1. StudyEvent: GOG Common Toxicity Reporting Form
    1. FORM T
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
Adverse Events - Section 1
CurrentCourseNumber
Item
Current course number (The toxicities listed below occurred following this course of therapy)
double
Item
Has the patient received any transfusions during this course of therapy?
text
CL.1
Code List
Has the patient received any transfusions during this course of therapy?
CL Item
No Transfusion (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Transfusion With Red Blood Cells (Yes, pRBC)
CL Item
Transfusion With Platelets (Yes, platelets)
Item
Was patient hospitalized as a result of reported adverse events?
text
CL.2
Code List
Was patient hospitalized as a result of reported adverse events?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Were cytokines administered this course?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C20464 (NCI Thesaurus Property)
C0079189 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.3
Code List
Were cytokines administered this course?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AgentCytokineAdministeredSpecify
Item
Yes (Cytokines), specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20464 (NCI Thesaurus Property)
C0079189 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Has an Adverse Drug Reaction Report been filed?
text
C25410 (NCI Thesaurus ObjectClass)
C1521800 (UMLS 2011AA ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
CL.4
Code List
Has an Adverse Drug Reaction Report been filed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Adverse Events - Section 2
Item
Peripheral WBC count, Done
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12529 (NCI Thesaurus Property)
C0023516 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
CL.5
Code List
Peripheral WBC count, Done
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Lab,Hematology,WBC
Item
Peripheral WBC count (1000/mm3 Nadir)
double
Lab,Hematology,WBCDate
Item
Peripheral WBC count, Date (m d y)
date
Item
Peripheral Granulocytes count, Done
text
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12530 (NCI Thesaurus Property)
C0018183 (UMLS 2011AA Property)
C63321 (NCI Thesaurus Property)
C0948762 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.6
Code List
Peripheral Granulocytes count, Done
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Lab,Hematology,GranulocyteCount
Item
Peripheral Granulocytes count (ANC, 1000/mm3 Nadir)
double
Lab,Hematology,GranDate
Item
Peripheral Granulocytes count, Date
date
Item
Peripheral Platelet count, Done
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12520 (NCI Thesaurus Property)
C0005821 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
CL.7
Code List
Peripheral Platelet count, Done
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Lab,Hematology,Platelets
Item
Peripheral Platelet count (mm3 Nadir)
double
Lab,Hematology,PlateletDate
Item
Peripheral Platelet count, Date
date
Item
Hemoglobin, Done
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16676 (NCI Thesaurus Property)
C0019046 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
CL.8
Code List
Hemoglobin, Done
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Lab,Hematology,Hemoglobin
Item
Hemoglobin (G/DL Nadir)
double
Lab,Hematology,HGBDate
Item
Hemoglobin, Date
date
CTCAdverseEventGrade
Item
CTC Adverse Event Grade
text
Item
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
text
CL.10
Code List
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 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
Adverse Events - Section 3
CTCAdverseEventTerm
Item
CTC Adverse Event Term
text
CTCAdverseEventGrade
Item
CTC Adverse Event Grade
text
Item
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
text
CL.10
Code List
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 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
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 Common Toxicity Reporting Form
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