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ID

2125

Description

E4599 Long-Term Follow-up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A13401E7-87EA-64C7-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A13401E7-87EA-64C7-E034-080020C9C0E0

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 12/12/14 12/12/14 - Martin Dugas
Uploaded on

September 19, 2012

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License

Creative Commons BY-NC 3.0 Legacy
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    Lung Cancer null Follow-Up - E4599 Long-Term Follow-up Form - 2036056v3.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: E4599 Long-Term Follow-up Form
      1. No Instruction available.
    Unnamed
    Description

    Unnamed

    Date of data transfer
    Description

    Dateofdatatransfer

    Data type

    text

    Transfer Method
    Description

    TransferMethod

    Data type

    text

    Specify other transfer method
    Description

    Specifyothertransfermethod

    Data type

    text

    Amended Data Ind
    Description

    AmendedDataInd

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Step No.
    Description

    StepNo.

    Data type

    text

    Patient Name
    Description

    PatientName

    Data type

    text

    Particip. Group Protocol Number
    Description

    Particip.GroupProtocolNumber

    Data type

    double

    Patient Study ID, Participating Group
    Description

    PatientStudyID,ParticipatingGroup

    Data type

    text

    Institution Name
    Description

    InstitutionName

    Data type

    text

    Affiliate Name
    Description

    AffiliateName

    Data type

    text

    Interval Report From Date
    Description

    IntervalReportFromDate

    Data type

    date

    Interval Report To Date
    Description

    IntervalReportToDate

    Data type

    date

    Patient's Vital Status
    Description

    Patient'sVitalStatus

    Data type

    text

    Death Reason
    Description

    DeathReason

    Data type

    text

    Death Date/Last Contact Date
    Description

    DeathDate/LastContactDate

    Data type

    date

    Death Reason, Specify
    Description

    DeathReason,Specify

    Data type

    text

    Cancer Follow-up Status Ind
    Description

    CancerFollow-upStatusInd

    Data type

    text

    Cancer Follow-up Status Date
    Description

    CancerFollow-upStatusDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Progression Ind
    Description

    ProgressionInd

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    Progression Date
    Description

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    Formal Progressive Disease Diagnosis
    Description

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    Progression Site
    Description

    ProgressionSite

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    New Primary Cancer Ind
    Description

    NewPrimaryCancerInd

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    New Primary Site
    Description

    NewPrimarySite

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    Late Adverse Event Ind
    Description

    LateAdverseEventInd

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    Non protocol therapy prior to first progression
    Description

    Nonprotocoltherapypriortofirstprogression

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    Second line therapy
    Description

    Secondlinetherapy

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    Type of Second Line Therapy
    Description

    TypeofSecondLineTherapy

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    Type of Second Line Chemotherapy
    Description

    TypeofSecondLineChemotherapy

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    Comments
    Description

    Comments

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    Comments2
    Description

    Comments2

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    New Primary Cancer Date
    Description

    NewPrimaryCancerDate

    Data type

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    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Non-Protocol Therapy Date, First
    Description

    Non-ProtocolTherapyDate,First

    Data type

    date

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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: E4599 Long-Term Follow-up Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Unnamed
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    Item
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    text
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    Transfer Method
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    Specifyothertransfermethod
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    AmendedDataInd
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    Amended Data Ind
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    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    StepNo.
    Item
    Step No.
    text
    PatientName
    Item
    Patient Name
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    Particip.GroupProtocolNumber
    Item
    Particip. Group Protocol Number
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    PatientStudyID,ParticipatingGroup
    Item
    Patient Study ID, Participating Group
    text
    InstitutionName
    Item
    Institution Name
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    AffiliateName
    Item
    Affiliate Name
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    IntervalReportFromDate
    Item
    Interval Report From Date
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    IntervalReportToDate
    Item
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    Patient'sVitalStatus
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    DeathReason
    Item
    Death Reason
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    DeathDate/LastContactDate
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    Death Date/Last Contact Date
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    DeathReason,Specify
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    CancerFollow-upStatusInd
    Item
    Cancer Follow-up Status Ind
    text
    CancerFollow-upStatusDate
    Item
    Cancer Follow-up Status Date
    date
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    ProgressionInd
    Item
    Progression Ind
    text
    ProgressionDate
    Item
    Progression Date
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    FormalProgressiveDiseaseDiagnosis
    Item
    Formal Progressive Disease Diagnosis
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    ProgressionSite
    Item
    Progression Site
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    Item
    New Primary Cancer Ind
    text
    NewPrimarySite
    Item
    New Primary Site
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    LateAdverseEventInd
    Item
    Late Adverse Event Ind
    text
    Nonprotocoltherapypriortofirstprogression
    Item
    Non protocol therapy prior to first progression
    text
    Secondlinetherapy
    Item
    Second line therapy
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    TypeofSecondLineTherapy
    Item
    Type of Second Line Therapy
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    TypeofSecondLineChemotherapy
    Item
    Type of Second Line Chemotherapy
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    Comments
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    Comments2
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    Comments2
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    NewPrimaryCancerDate
    Item
    New Primary Cancer Date
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    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Non-ProtocolTherapyDate,First
    Item
    Non-Protocol Therapy Date, First
    date
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