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1813

Description

RTOG-0421 I6: Radiation Therapy Oncology Group Phase III Recurrent Head and Neck Study Staging Diagrams / Oral Cavity Combination Chemotherapy With or Without Radiation Therapy in Treating Patients With Recurrent Head and Neck Cancer That Cannot Be Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EB499DEC-47D0-3F31-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EB499DEC-47D0-3F31-E034-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 3/30/15 3/30/15 - Martin Dugas
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September 19, 2012

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Creative Commons BY-NC 3.0 Legacy
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    Head and Neck Cancer NCT00113399 On-Study - RTOG-0421 I6: Radiation Therapy Oncology Group Phase III Recurrent Head and Neck Study Staging Diagrams / Oral Cavity - 2265793v3.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: RTOG-0421 I6: Radiation Therapy Oncology Group Phase III Recurrent Head and Neck Study Staging Diagrams / Oral Cavity
      1. No Instruction available.
    Unnamed Module 1
    Description

    Unnamed Module 1

    RTOG Study
    Description

    ProtocolRTOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C19778
    UMLS 2011AA Property
    C1514695
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Case #
    Description

    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass
    C19778
    UMLS 2011AA ObjectClass
    C1514695
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C49152
    UMLS 2011AA Property
    C1706256
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Institution Name
    Description

    InstitutionName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Institution No.
    Description

    InstitutionIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Initials
    Description

    PatientInitialsName

    Data type

    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
    Patient Study No.
    Description

    PatientRadiationTherapyOncologyGroupIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C19778
    UMLS 2011AA Property
    C1514695
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    If this is a revised or corrected form, indicate by checking box.
    Description

    CaseReportFormModifiedInd-2

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C40988
    UMLS 2011AA ObjectClass
    C1516308
    NCI Thesaurus Property
    C25573
    Unamed Module 2
    Description

    Unamed Module 2

    Indicate side of lesion (R or L)
    Description

    HeadandNeckTumorSideType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C12418
    UMLS 2011AA ObjectClass
    C0460004
    NCI Thesaurus Property
    C25306
    UMLS 2011AA Property
    C0441987
    CHARACTERISTICS OF TUMOR
    Description

    HeadandNeckTumorCharacteristicsType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C12418
    UMLS 2011AA ObjectClass
    C0460004
    NCI Thesaurus Property
    C25447
    UMLS 2011AA Property
    C1521970
    LOCATION OF TUMOR ( all that apply)
    Description

    HeadandNeckTumorSite

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus ObjectClass
    C12418
    UMLS 2011AA ObjectClass
    C0460004
    SITE OF ORIGIN
    Description

    HeadandNeckTumorOriginLocationStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C12418
    UMLS 2011AA ObjectClass
    C0460004
    NCI Thesaurus ObjectClass
    C3077
    UMLS 2011AA ObjectClass
    C0018671
    NCI Thesaurus Property
    C13717
    UMLS 2011AA Property
    C1515974
    NCI Thesaurus Property
    C42703
    UMLS 2011AA Property
    C0439659
    NCI Metathesaurus ValueDomain
    CL052713
    SITE(S) ALSO INVOLVED
    Description

    HeadandNeckTumorInvolvedLocationStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C12418
    UMLS 2011AA ObjectClass
    C0460004
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property
    C25547
    NCI Metathesaurus ValueDomain
    CL052713
    Signature
    Description

    Signature

    Data type

    text

    Date
    Description

    ResponsiblePersonSignatureDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: RTOG-0421 I6: Radiation Therapy Oncology Group Phase III Recurrent Head and Neck Study Staging Diagrams / Oral Cavity
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Unnamed Module 1
    ProtocolRTOGIdentifierNumber
    Item
    RTOG Study
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C19778 (NCI Thesaurus Property)
    C1514695 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
    Item
    Case #
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C19778 (NCI Thesaurus ObjectClass)
    C1514695 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C49152 (NCI Thesaurus Property)
    C1706256 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    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)
    InstitutionIdentifierNumber
    Item
    Institution No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientInitialsName
    Item
    Patient Initials
    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)
    PatientRadiationTherapyOncologyGroupIdentifierNumber
    Item
    Patient Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C19778 (NCI Thesaurus Property)
    C1514695 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CaseReportFormModifiedInd-2
    Item
    If this is a revised or corrected form, indicate by checking box.
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C25573 (NCI Thesaurus Property)
    Item Group
    Unamed Module 2
    HeadandNeckTumorSideType
    Item
    Indicate side of lesion (R or L)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass)
    C0460004 (UMLS 2011AA ObjectClass)
    C25306 (NCI Thesaurus Property)
    C0441987 (UMLS 2011AA Property)
    Item
    CHARACTERISTICS OF TUMOR
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass)
    C0460004 (UMLS 2011AA ObjectClass)
    C25447 (NCI Thesaurus Property)
    C1521970 (UMLS 2011AA Property)
    CL.1
    Code List
    CHARACTERISTICS OF TUMOR
    CL Item
    Deeply Infiltrating (Deeply infiltrating)
    CL Item
    Normal Mobility Of Tongue (Normal mobility of tongue)
    CL Item
    Impaired Mobility Of Tongue (Impaired mobility of tongue)
    CL Item
    Fixed Tongue (Fixed tongue)
    CL Item
    Gross Erosion Of Bone (Gross erosion of bone)
    CL Item
    Radiographic Bone Destruction (Radiographic bone destruction)
    Item
    LOCATION OF TUMOR ( all that apply)
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C12418 (NCI Thesaurus ObjectClass)
    C0460004 (UMLS 2011AA ObjectClass)
    CL.2
    Code List
    LOCATION OF TUMOR ( all that apply)
    CL Item
    Oral Tongue (Oral tongue)
    CL Item
    Floor Of Mouth (Floor of mouth)
    C0026638 (NCI Metathesaurus)
    CL Item
    Retromolar Trigone (Retromolar Trigone)
    CL Item
    Upper Gingiva (Upper gingiva)
    CL Item
    Lower Gingiva (Lower gingiva)
    CL Item
    Buccal Mucosa (Buccal mucosa)
    C12505 (NCI Thesaurus)
    C1578559 (UMLS 2011AA)
    CL Item
    Hard Palate (Hard palate)
    C12230 (NCI Thesaurus)
    C0226901 (UMLS 2011AA)
    CL Item
    Upper gingiva (Upper gingiva)
    CL Item
    Upper Lip (Upper lip)
    CL Item
    Lower Lip (Lower lip)
    CL Item
    Commissure (Commissure)
    Item
    SITE OF ORIGIN
    text
    C12418 (NCI Thesaurus ObjectClass)
    C0460004 (UMLS 2011AA ObjectClass)
    C3077 (NCI Thesaurus ObjectClass)
    C0018671 (UMLS 2011AA ObjectClass)
    C13717 (NCI Thesaurus Property)
    C1515974 (UMLS 2011AA Property)
    C42703 (NCI Thesaurus Property)
    C0439659 (UMLS 2011AA Property)
    CL052713 (NCI Metathesaurus ValueDomain)
    CL.3
    Code List
    SITE OF ORIGIN
    CL Item
    Right (RT)
    C25228 (NCI Thesaurus)
    C0205090 (UMLS 2011AA)
    CL Item
    Left (LT)
    C25229 (NCI Thesaurus)
    C0205091 (UMLS 2011AA)
    Item
    SITE(S) ALSO INVOLVED
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass)
    C0460004 (UMLS 2011AA ObjectClass)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25547 (NCI Thesaurus Property)
    CL052713 (NCI Metathesaurus ValueDomain)
    CL.4
    Code List
    SITE(S) ALSO INVOLVED
    CL Item
    Right (RT)
    C25228 (NCI Thesaurus)
    C0205090 (UMLS 2011AA)
    CL Item
    Left (LT)
    C25229 (NCI Thesaurus)
    C0205091 (UMLS 2011AA)
    Signature
    Item
    Signature
    text
    ResponsiblePersonSignatureDate
    Item
    Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
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