ID

1614

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 28-05-15 28-05-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

19 september 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Esophageal Cancer NCT00052910 On-Study - CALGB: 80101 ON-STUDY FORM - 2030014v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Unnamed1
Beschrijving

Unnamed1

CALGB Form
Beschrijving

CALGBForm

Datatype

text

CALGB Study No
Beschrijving

CALGBProtocolNumber

Datatype

text

CALGB Patient ID
Beschrijving

CALGBPatientID

Datatype

text

Amended data?
Beschrijving

AmendedDataInd

Datatype

text

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

Unnamed2

Patient's Name
Beschrijving

PatientName,Last

Datatype

text

Participating Group
Beschrijving

ParticipatingGroupCode

Datatype

text

Patient Hospital Number
Beschrijving

PatientMedicalRecordNumber

Datatype

text

Participating Group Protocol No.
Beschrijving

Particip.GroupProtocolNumber

Datatype

double

Main Member Institution/Adjunct
Beschrijving

InstitutionName

Datatype

text

Participating Group Patient No.
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Unnamed3
Beschrijving

Unnamed3

History of primary cancer other than gastric?
Beschrijving

PriorCancerInd

Datatype

text

Yes, specify type of cancer
Beschrijving

PriorCancerType

Datatype

text

Year of diagnosis
Beschrijving

PriorCancerDiagnosisDate

Datatype

date

Caloric intake >/= 1500 Kcal/day
Beschrijving

Caloricintake>/=1500Kcal/day

Datatype

text

Lab Data At Protocol Entry
Beschrijving

Lab Data At Protocol Entry

ANC (x10 3)
Beschrijving

Lab,Hematology,NeutrophilCount

Datatype

double

Platelets (x10 3)
Beschrijving

Lab,Hematology,Platelets

Datatype

double

Serum Creatinine (mg/dl)
Beschrijving

Lab,Renal,Creatinine

Datatype

double

SGOT (U/ml)
Beschrijving

Lab,Hepatic,SGOT

Datatype

double

Bilirubin (mg/dl)
Beschrijving

Lab,Hepatic,Bilirubin

Datatype

double

Patient examined by RT oncologist?
Beschrijving

PatientexaminedbyRToncologist?

Datatype

text

Bilateral renal function as determined by scan?
Beschrijving

Bilateralrenalfunctionasdeterminedbyscan?

Datatype

text

Prior systemic chemotherapy?
Beschrijving

PriorChemotherapyInd

Datatype

text

Prior immunotherapy?
Beschrijving

PriorImmunotherapyInd

Datatype

text

Prior radiotherapy?
Beschrijving

PriorRTInd

Datatype

text

Gastric Resection Data
Beschrijving

Gastric Resection Data

Date of gastric resection
Beschrijving

GastricResectionDate

Datatype

text

Site of gastric primary
Beschrijving

PrimarySite

Datatype

text

Name of institution where resection was done
Beschrijving

InstitutionName,Resection

Datatype

text

Medicare ID number of institution
Beschrijving

ProfessionalOrganizationMedicareIdentifierNumber

Datatype

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
Beschrijving

Histology & Staging Data

Differentiation
Beschrijving

HistologicGrade

Datatype

text

AJCC/UICC TNM Staging: T
Beschrijving

TStage,Clinical

Datatype

text

AJCC/UICC TNM Staging: N
Beschrijving

NStage,Clinical

Datatype

text

AJCC/UICC TNM Staging: M
Beschrijving

MStage,Clinical

Datatype

text

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

IfpatienthasT2N0M0,doestumorextendbeyondmuscularispropria?

Datatype

text

Completed by
Beschrijving

PersonCompletingForm,FirstName

Datatype

text

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

FormCompletionDate,Original

Datatype

date

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
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