0 Evaluaciones
ID

1315

Descripción

NSABP PROTOCOL C-08: MENSTRUAL STATUS FORM Fluorouracil, Leucovorin, and Oxaliplatin With or Without Bevacizumab in Treating Patients Who Have Undergone Surgery for Stage II or Stage III Colon Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7F6C655-DE00-4623-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7F6C655-DE00-4623-E034-0003BA12F5E7

Palabras clave

Versiones (3)
  1. 27/8/12 27/8/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 3/7/15 3/7/15 -
Subido en

27 de agosto de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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    Colorectal Cancer NCT00096278 Follow-Up - NSABP PROTOCOL C-08: MENSTRUAL STATUS FORM - 2276688v3.0

    Inglés

    This form should be completed for female subjects who were pre-menopausal at randomization.

    1 formularios  
    Unnamed1
    Descripción

    Unnamed1

    Patient Initials (Last, First Middle)
    Descripción

    PatientInitialsName

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25536 (undefined)
    UMLS 2011AA Property
    C1555582 (Initial (abbreviation))
    NSABP Patient ID
    Descripción

    PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property
    C15818 (undefined)
    UMLS 2011AA Property
    C1513905 (National Surgical Adjuvant Breast and Bowel Project)
    LOINC
    LA4707-1
    Institution Name
    Descripción

    InstitutionName

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ObjectClass
    C21541 (undefined)
    UMLS 2011AA ObjectClass
    C0018704 (Health care facility)
    SNOMED
    257622000
    LOINC
    LA30302-6
    NCI Thesaurus ValueDomain
    C21541 (undefined)
    UMLS 2011AA ValueDomain
    C0018704 (Health care facility)
    SNOMED
    257622000
    LOINC
    LA30302-6
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    Affiliate Name
    Descripción

    AffiliatedInstitutionName

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C21541 (undefined)
    UMLS 2011AA ObjectClass
    C0018704 (Health care facility)
    SNOMED
    257622000
    LOINC
    LA30302-6
    NCI Thesaurus ObjectClass
    C25413 (undefined)
    UMLS 2011AA ObjectClass
    C1510826 (Affiliated)
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ValueDomain
    C21541 (undefined)
    UMLS 2011AA ValueDomain
    C0018704 (Health care facility)
    SNOMED
    257622000
    LOINC
    LA30302-6
    Person Completing Form Last Name
    Descripción

    ResponsiblePersonLastName

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190 (undefined)
    UMLS 2011AA ObjectClass
    C0027361 (Persons)
    SNOMED
    125676002
    NCI Thesaurus ObjectClass
    C25657 (undefined)
    UMLS 2011AA ObjectClass
    C1273518 (Responsible to (attribute))
    SNOMED
    394851003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property
    C25551 (undefined)
    UMLS 2011AA Property
    C1517741 (Last)
    LOINC
    LP200101-6
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    Person Completing Form First Name
    Descripción

    ResponsiblePersonFirstName

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190 (undefined)
    UMLS 2011AA ObjectClass
    C0027361 (Persons)
    SNOMED
    125676002
    NCI Thesaurus ObjectClass
    C25657 (undefined)
    UMLS 2011AA ObjectClass
    C1273518 (Responsible to (attribute))
    SNOMED
    394851003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property
    C25509 (undefined)
    UMLS 2011AA Property
    C1279901 (Firstly)
    SNOMED
    232714002
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    Person Completing Form Phone
    Descripción

    ResponsiblePersonPhoneNumber

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C25190 (undefined)
    UMLS 2011AA ObjectClass
    C0027361 (Persons)
    SNOMED
    125676002
    NCI Thesaurus ObjectClass
    C25657 (undefined)
    UMLS 2011AA ObjectClass
    C1273518 (Responsible to (attribute))
    SNOMED
    394851003
    NCI Thesaurus Property
    C25395 (undefined)
    UMLS 2011AA Property
    C0039457 (Telephone)
    SNOMED
    359993007
    LOINC
    LA26664-5
    Are data amended? (check box if yes, and circle amended items)
    Descripción

    DataAmendedInd-3

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS 2011AA ValueDomain
    C1512699 (Yes, No, or Unknown Response)
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    UMLS 2011AA ObjectClass
    C1511726 (Data)
    NCI Thesaurus Property
    C25416 (undefined)
    UMLS 2011AA Property
    C1691222 (Amended)
    Unnamed2
    Descripción

    Unnamed2

    Time Point of this Assessment
    Descripción

    AssessmentPeriodType

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    NCI Thesaurus ObjectClass
    C20989 (undefined)
    UMLS 2011AA ObjectClass
    C0031809 (Physical Examination)
    SNOMED
    5880005
    LOINC
    MTHU028014
    NCI Thesaurus Property
    C25616 (undefined)
    UMLS 2011AA Property
    C1948053 (Period (temporal qualifier))
    SNOMED
    272117007
    Date of Assessment (month day year)
    Descripción

    AssessmentPerformedDate

    Tipo de datos

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25367 (undefined)
    NCI Thesaurus ValueDomain
    C25367 (undefined)
    NCI Thesaurus Property
    C38000 (undefined)
    UMLS 2011AA Property
    C0884358 (Performed)
    SNOMED
    398166005
    LOINC
    LA19974-7
    Date of Last Menstrual Period (month day year)
    Descripción

    MenstrualCycleAssessmentInd-2

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    UMLS 2011AA ValueDomain
    C1512698 (Yes or No Response)
    NCI Thesaurus Property
    C20989 (undefined)
    UMLS 2011AA Property
    C0031809 (Physical Examination)
    SNOMED
    5880005
    LOINC
    MTHU028014
    NCI Thesaurus ObjectClass
    C16838 (undefined)
    UMLS 2011AA ObjectClass
    C0025329 (Menstrual cycle)
    SNOMED
    78456001
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    Similar models

    This form should be completed for female subjects who were pre-menopausal at randomization.

    1 formularios
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de datos
    Alias
    Item Group
    Unnamed1
    PatientInitialsName
    Item
    Patient Initials (Last, First Middle)
    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)
    PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber
    Item
    NSABP Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C15818 (NCI Thesaurus Property)
    C1513905 (UMLS 2011AA Property)
    InstitutionName
    Item
    Institution Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    AffiliatedInstitutionName
    Item
    Affiliate Name
    text
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25413 (NCI Thesaurus ObjectClass)
    C1510826 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    ResponsiblePersonLastName
    Item
    Person Completing Form Last Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus Property)
    C1517741 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    ResponsiblePersonFirstName
    Item
    Person Completing Form First Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    ResponsiblePersonPhoneNumber
    Item
    Person Completing Form Phone
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    Item
    Are data amended? (check box if yes, and circle amended items)
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    CL.1
    Code List
    Are data amended? (check box if yes, and circle amended items)
    CL Item
    Yes (yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item Group
    Unnamed2
    Item
    Time Point of this Assessment
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus ObjectClass)
    C0031809 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    CL.2
    Code List
    Time Point of this Assessment
    CL Item
    6 Months (6 months)
    CL Item
    12 Months (12 months)
    CL Item
    18 Months (18 months)
    CL Item
    24 Months (24 months)
    AssessmentPerformedDate
    Item
    Date of Assessment (month day year)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Item
    Date of Last Menstrual Period (month day year)
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C16838 (NCI Thesaurus ObjectClass)
    C0025329 (UMLS 2011AA ObjectClass)
    CL.3
    Code List
    Date of Last Menstrual Period (month day year)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
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