ID

2133

Description

Southwest Oncology Group Lung Carcinoma Follow Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CDF62A-7230-112A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CDF62A-7230-112A-E034-080020C9C0E0

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
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 - Southwest Oncology Group Lung Carcinoma Follow Up Form - 2040560v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Southwest Oncology Group Lung Carcinoma Follow Up Form
    1. No Instruction available.
Unnamed 1
Description

Unnamed 1

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
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
Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Physician (Groups other than SWOG)
Description

RegisteredInvestigator

Data type

text

Group Name
Description

GroupName

Data type

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.

Data type

text

Pt. ID (Vital Status)
Description

Pt.ID

Data type

text

Unnamed 2
Description

Unnamed 2

Vital Status
Description

Patient'sVitalStatus

Data type

text

Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
Description

DeathDate/LastContactDate

Data type

date

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Description

CancerFollow-upStatusInd

Data type

text

Date of Last Clinical Assessment (Notice of First Relapse or Progression)
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Has the patient developed a first progression (or relapse) that has not been previously reported?
Description

ProgressionInd

Data type

text

Date of Relapse or Progression (If yes, please submit the Lung Carcinoma First Sites of Progression or Relapse Form.)
Description

ProgressionDate

Data type

date

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If yes,)
Description

NewPrimaryCancerInd

Data type

text

Date of Diagnosis
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site (Further Treatment)
Description

NewPrimarySite

Data type

text

Has the patient received further (non-protocol) treatment for this cancer? (If yes,)
Description

Non-ProtocolTherapyInd

Data type

text

Date of first non-protocol therapy
Description

Non-ProtocolTherapyDate,First

Data type

date

Specify regimen (Note: If multiple regimens were received, please specify only the first regimen received after going off protocol treatment.)
Description

Non-ProtocolTherapyType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass
C2167
UMLS 2011AA ObjectClass
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Did the patient respond to this treatment?
Description

Didthepatientrespondtothistreatment?

Data type

text

Has the patient received prophylactic cranial irradiation (PCI)?
Description

PatientProphylacticCranialIrradiationReceivedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C15913
UMLS 2011AA Property
C1514496
PCI Start Date (Long Term Toxicity)
Description

PCIStartDate

Data type

text

Toxicities and Grades
Description

CTCAdverseEventTerm

Data type

text

Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade>/=3) long term toxicity that has not been previously reported?
Description

Hasthepatientexperienced(priortotreatmentforprogressionorrelapseorasecondprimary,andpriortonon-protocoltreatment)anysevere(grade>/=3)longtermtoxicitythathasnotbeenpreviouslyreported?

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form
Description

Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Southwest Oncology Group Lung Carcinoma Follow Up Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed 1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitialsName
Item
Patient Initials (L, F M)
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)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
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 (Vital Status)
text
Item Group
Unnamed 2
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
date
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
text
CL.2
Code List
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment (Notice of First Relapse or Progression)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Has the patient developed a first progression (or relapse) that has not been previously reported?
text
CL.3
Code List
Has the patient developed a first progression (or relapse) that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate
Item
Date of Relapse or Progression (If yes, please submit the Lung Carcinoma First Sites of Progression or Relapse Form.)
date
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If yes,)
text
CL.4
Code List
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If yes,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimaryCancerDate
Item
Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site (Further Treatment)
text
Item
Has the patient received further (non-protocol) treatment for this cancer? (If yes,)
text
CL.5
Code List
Has the patient received further (non-protocol) treatment for this cancer? (If yes,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Non-ProtocolTherapyType
Item
Specify regimen (Note: If multiple regimens were received, please specify only the first regimen received after going off protocol treatment.)
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass)
C1443775 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Did the patient respond to this treatment?
text
CL.6
Code List
Did the patient respond to this treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Has the patient received prophylactic cranial irradiation (PCI)?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C15913 (NCI Thesaurus Property)
C1514496 (UMLS 2011AA Property)
CL.7
Code List
Has the patient received prophylactic cranial irradiation (PCI)?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PCIStartDate
Item
PCI Start Date (Long Term Toxicity)
text
CTCAdverseEventTerm
Item
Toxicities and Grades
text
Item
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade>/=3) long term toxicity that has not been previously reported?
text
CL.8
Code List
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade>/=3) long term toxicity that has not been previously reported?
CL Item
No (No)
CL Item
Yes (Yes)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form
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