ID

1902

Description

S0100 OFF TREATMENT NOTICE Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB544B0-C752-4414-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB544B0-C752-4414-E034-0003BA12F5E7

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 28/05/2015 28/05/2015 -
Téléchargé le

19 septembre 2012

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Retour au modèle Commentaires
Groupe Item commentaires pour :

Item commentaires pour :

Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

Leukemia null Follow-Up - S0100 OFF TREATMENT NOTICE - 2071753v3.0

Anglais

No Instruction available.

1 Formulaires  
  1. StudyEvent: S0100 OFF TREATMENT NOTICE
    1. No Instruction available.
Unnamed 1
Description

Unnamed 1

SWOG Patient ID
Description

SWOGPatientID

Type de données

text

SWOG Study No.
Description

SWOGStudyNo.

Type de données

text

Registration Step
Description

RegistrationStep

Type de données

text

Patient Initials (L, F M)
Description

PatientInitials

Type de données

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Type de données

text

Physician (Groups other than SWOG)
Description

TreatingPhysician

Type de données

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Group Name
Description

GroupName

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study No.
Description

StudyNo.

Type de données

text

Pt. ID
Description

Pt.ID

Type de données

text

Unnamed 2
Description

Unnamed 2

Treatment Start Date
Description

TreatmentStartDate

Type de données

date

Treatment End Date
Description

TreatmentEndDate

Type de données

date

Regimen or Procedure or Site(s) (If more room is needed, please continue on a separate page.)
Description

RegimenorProcedureorSite(s)

Type de données

text

Off Treatment Reason (select one)
Description

OffTreatmentReason

Type de données

text

Patient refused, due to toxicity, specify
Description

OffTreatmentReason,Toxicity

Type de données

text

Patient refused, due to toxicity, specify
Description

OffTreatmentReason,Toxicity

Type de données

text

Sites (progression or relapse)
Description

Progressionorrelapse,specifysite

Type de données

text

Other, specify (Off Treatment Date)
Description

OffTreatmentReason,Other

Type de données

text

Other, specify (Off Treatment Date)
Description

OffTreatmentReason,Other

Type de données

text

Date of completion, progression, death or decision to discontinue therapy
Description

Dateofcompletion,progression,deathordecisiontodiscontinuetherapy

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Will patient receive further treatment?
Description

FurtherTreatmentInd

Type de données

text

Yes, specify (further treatment)
Description

FurtherTreatmentSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C25519
UMLS 2011AA ObjectClass
C1517331
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Date of Last Contact (or death)
Description

DeathDate/LastContactDate

Type de données

date

Vital Status
Description

Patient'sVitalStatus

Type de données

text

Comments
Description

Comments

Comments
Description

Comments

Type de données

text

Ccrr Module For S0100 Off Treatment Notice
Description

Ccrr Module For S0100 Off Treatment Notice

Retour au début de la page

Similar models

No Instruction available.

1 Formulaires
  1. StudyEvent: S0100 OFF TREATMENT NOTICE
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Unnamed 1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F M)
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician (Groups other than SWOG)
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID
text
Item Group
Unnamed 2
TreatmentStartDate
Item
Treatment Start Date
date
TreatmentEndDate
Item
Treatment End Date
date
RegimenorProcedureorSite(s)
Item
Regimen or Procedure or Site(s) (If more room is needed, please continue on a separate page.)
text
Item
Off Treatment Reason (select one)
text
CL.1
Code List
Off Treatment Reason (select one)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Medically required, due to toxicity, specify (Medically required, due to toxicity, specify)
CL Item
Patient refused, due to toxicity, specify (Patient refused, due to toxicity, specify)
CL Item
Patient refused, other than toxicity, specify (Patient refused, other than toxicity, specify)
CL Item
Progression or relapse (Progression or relapse)
CL Item
Death (Death)
CL Item
Other, Specify (Other, specify)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Death Of Patient Occurred After The Patient Began Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death On Study (Death on study)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Progression Of Disease Occurred Prior To The Patient Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Toxicity/side Effects/complications (Toxicity/Side effects/Complications)
OffTreatmentReason,Toxicity
Item
Patient refused, due to toxicity, specify
text
OffTreatmentReason,Toxicity
Item
Patient refused, due to toxicity, specify
text
Progressionorrelapse,specifysite
Item
Sites (progression or relapse)
text
OffTreatmentReason,Other
Item
Other, specify (Off Treatment Date)
text
OffTreatmentReason,Other
Item
Other, specify (Off Treatment Date)
text
Dateofcompletion,progression,deathordecisiontodiscontinuetherapy
Item
Date of completion, progression, death or decision to discontinue therapy
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Will patient receive further treatment?
text
CL.2
Code List
Will patient receive further treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
FurtherTreatmentSpecify
Item
Yes, specify (further treatment)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25519 (NCI Thesaurus ObjectClass)
C1517331 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
DeathDate/LastContactDate
Item
Date of Last Contact (or death)
date
Item
Vital Status
text
CL.3
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0100 Off Treatment Notice
Retour au début de la page 

Contact

Utilisez ce formulaire pour les retours, les questions et les améliorations suggérées.

Les champs marqués d’un * sont obligatoires.

Aide

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