ID

1614

Descripción

CALGB: 80101 ON-STUDY FORM Chemotherapy and Radiation Therapy After Surgery in Treating Patients With Stomach or Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA712C5-6067-535F-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA712C5-6067-535F-E034-080020C9C0E0

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 28/5/15 28/5/15 -
  3. 3/6/15 3/6/15 -
Subido en

19 de septiembre de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
Comentarios del modelo :

Puede comentar sobre el modelo de datos aquí. A través de las burbujas de diálogo en los grupos de elementos y elementos, puede agregar comentarios específicos.

Volver a los comentarios del modelo
Comentarios de grupo de elementos para :

Comentarios del elemento para :

Para descargar modelos de datos, debe haber iniciado sesión. Por favor iniciar sesión o Registrate gratis.

Esophageal Cancer NCT00052910 On-Study - CALGB: 80101 ON-STUDY FORM - 2030014v3.0

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Unnamed1
Descripción

Unnamed1

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBProtocolNumber

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

Amended data?
Descripción

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Descripción

Unnamed2

Patient's Name
Descripción

PatientName,Last

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroupCode

Tipo de datos

text

Patient Hospital Number
Descripción

PatientMedicalRecordNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

Particip.GroupProtocolNumber

Tipo de datos

double

Main Member Institution/Adjunct
Descripción

InstitutionName

Tipo de datos

text

Participating Group Patient No.
Descripción

PatientStudyID,ParticipatingGroup

Tipo de datos

text

Unnamed3
Descripción

Unnamed3

History of primary cancer other than gastric?
Descripción

PriorCancerInd

Tipo de datos

text

Yes, specify type of cancer
Descripción

PriorCancerType

Tipo de datos

text

Year of diagnosis
Descripción

PriorCancerDiagnosisDate

Tipo de datos

date

Caloric intake >/= 1500 Kcal/day
Descripción

Caloricintake>/=1500Kcal/day

Tipo de datos

text

Lab Data At Protocol Entry
Descripción

Lab Data At Protocol Entry

ANC (x10 3)
Descripción

Lab,Hematology,NeutrophilCount

Tipo de datos

double

Platelets (x10 3)
Descripción

Lab,Hematology,Platelets

Tipo de datos

double

Serum Creatinine (mg/dl)
Descripción

Lab,Renal,Creatinine

Tipo de datos

double

SGOT (U/ml)
Descripción

Lab,Hepatic,SGOT

Tipo de datos

double

Bilirubin (mg/dl)
Descripción

Lab,Hepatic,Bilirubin

Tipo de datos

double

Patient examined by RT oncologist?
Descripción

PatientexaminedbyRToncologist?

Tipo de datos

text

Bilateral renal function as determined by scan?
Descripción

Bilateralrenalfunctionasdeterminedbyscan?

Tipo de datos

text

Prior systemic chemotherapy?
Descripción

PriorChemotherapyInd

Tipo de datos

text

Prior immunotherapy?
Descripción

PriorImmunotherapyInd

Tipo de datos

text

Prior radiotherapy?
Descripción

PriorRTInd

Tipo de datos

text

Gastric Resection Data
Descripción

Gastric Resection Data

Date of gastric resection
Descripción

GastricResectionDate

Tipo de datos

text

Site of gastric primary
Descripción

PrimarySite

Tipo de datos

text

Name of institution where resection was done
Descripción

InstitutionName,Resection

Tipo de datos

text

Medicare ID number of institution
Descripción

ProfessionalOrganizationMedicareIdentifierNumber

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C16665
UMLS 2011AA Property
C0018717
NCI Thesaurus ObjectClass
C19711
UMLS 2011AA ObjectClass
C1522486
Histology & Staging Data
Descripción

Histology & Staging Data

Differentiation
Descripción

HistologicGrade

Tipo de datos

text

AJCC/UICC TNM Staging: T
Descripción

TStage,Clinical

Tipo de datos

text

AJCC/UICC TNM Staging: N
Descripción

NStage,Clinical

Tipo de datos

text

AJCC/UICC TNM Staging: M
Descripción

MStage,Clinical

Tipo de datos

text

If patient has T2N0M0, does tumor extend beyond muscularis propria?
Descripción

IfpatienthasT2N0M0,doestumorextendbeyondmuscularispropria?

Tipo de datos

text

Completed by
Descripción

PersonCompletingForm,FirstName

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date completed
Descripción

FormCompletionDate,Original

Tipo de datos

date

Volver a la parte superior de la página

Similar models

No Instruction available.

1 formularios
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
PatientName,Last
Item
Patient's Name
text
ParticipatingGroupCode
Item
Participating Group
text
PatientMedicalRecordNumber
Item
Patient Hospital Number
text
Particip.GroupProtocolNumber
Item
Participating Group Protocol No.
double
InstitutionName
Item
Main Member Institution/Adjunct
text
PatientStudyID,ParticipatingGroup
Item
Participating Group Patient No.
text
Item Group
Unnamed3
Item
History of primary cancer other than gastric?
text
CL.2
Code List
History of primary cancer other than gastric?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, specify type of cancer (Yes, specify type of cancer)
PriorCancerType
Item
Yes, specify type of cancer
text
PriorCancerDiagnosisDate
Item
Year of diagnosis
date
Item
Caloric intake >/= 1500 Kcal/day
text
CL.3
Code List
Caloric intake >/= 1500 Kcal/day
CL Item
No (No)
CL Item
Yes (Yes)
Item Group
Lab Data At Protocol Entry
Lab,Hematology,NeutrophilCount
Item
ANC (x10 3)
double
Lab,Hematology,Platelets
Item
Platelets (x10 3)
double
Lab,Renal,Creatinine
Item
Serum Creatinine (mg/dl)
double
Lab,Hepatic,SGOT
Item
SGOT (U/ml)
double
Lab,Hepatic,Bilirubin
Item
Bilirubin (mg/dl)
double
PatientexaminedbyRToncologist?
Item
Patient examined by RT oncologist?
text
Bilateralrenalfunctionasdeterminedbyscan?
Item
Bilateral renal function as determined by scan?
text
PriorChemotherapyInd
Item
Prior systemic chemotherapy?
text
PriorImmunotherapyInd
Item
Prior immunotherapy?
text
PriorRTInd
Item
Prior radiotherapy?
text
Item Group
Gastric Resection Data
GastricResectionDate
Item
Date of gastric resection
text
Item
Site of gastric primary
text
CL.4
Code List
Site of gastric primary
CL Item
GE junction (GE junction)
CL Item
Cardia (Cardia)
C0007144 (NCI Metathesaurus)
CL Item
Fundus (Fundus)
C13378 (NCI Thesaurus)
C0740422 (UMLS 2011AA)
CL Item
Antrum (Antrum)
CL Item
Pylorus (Pylorus)
CL Item
Stomach, Not Otherwise Specified (Stomach, NOS)
InstitutionName,Resection
Item
Name of institution where resection was done
text
ProfessionalOrganizationMedicareIdentifierNumber
Item
Medicare ID number of institution
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C16665 (NCI Thesaurus Property)
C0018717 (UMLS 2011AA Property)
C19711 (NCI Thesaurus ObjectClass)
C1522486 (UMLS 2011AA ObjectClass)
Item Group
Histology & Staging Data
Item
Differentiation
text
CL.5
Code List
Differentiation
CL Item
Tumor Is Well Differentiated According To Who Grading System (Well differentiated (grade I))
CL Item
Moderately well differentiated (grade II) (Moderately well differentiated (grade II))
CL Item
Tumor Is Poorly Differentiated According To Who Grading System (Poorly differentiated (grade III))
CL Item
Tumor Is Undifferentiated According To Who Grading System (Undifferentiated (grade IV))
TStage,Clinical
Item
AJCC/UICC TNM Staging: T
text
NStage,Clinical
Item
AJCC/UICC TNM Staging: N
text
MStage,Clinical
Item
AJCC/UICC TNM Staging: M
text
Item
If patient has T2N0M0, does tumor extend beyond muscularis propria?
text
CL.6
Code List
If patient has T2N0M0, does tumor extend beyond muscularis propria?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PersonCompletingForm,FirstName
Item
Completed by
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date completed
date
Volver a la parte superior de la página 

Contacto

Utilice este formulario para comentarios, preguntas y sugerencias.

Los campos marcados con * son obligatorios.

Ayuda

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial