ID

2158

Description

S0023 LUNG CARCINOMA FOLLOW UP FORM S0023: Combination Chemo Plus RT With or Without Gefitinib in Treating Patients With Unresectable Stage III NSCLC Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CB6D1D2-A964-34E4-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CB6D1D2-A964-34E4-E034-080020C9C0E0

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00020709 Follow-Up - S0023 LUNG CARCINOMA FOLLOW UP FORM - 2030090v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0023 LUNG CARCINOMA FOLLOW UP FORM
    1. No Instruction available.
Unnamed1
Description

Unnamed1

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Patient Initials (L, F,M)
Description

PatientInitials

Data type

text

Institution / Affiliate
Description

Institution/Affiliate

Data type

text

Physician
Description

Physician

Data type

text

Group Name (Groups other than SWOG )
Description

GroupName

Data type

text

Study No. (Groups other than SWOG )
Description

StudyNo.

Data type

double

Pt. ID (Groups other than SWOG )
Description

Pt.ID

Data type

text

Vital Status
Description

Vital Status

Vital Status
Description

VitalStatus:

Data type

text

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

Dateoflastcontactordeath:

Data type

text

Disease Follow Up Status
Description

Disease Follow Up Status

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

Hasthepatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?

Data type

text

If Yes, Date of Last Clinical Assessment
Description

IfYes,DateofLastClinicalAssessment:

Data type

text

Has the patient developed a first relapse or progression that has not been previously reported?
Description

Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?

Data type

text

If Yes, Date of Relapse or Progression
Description

IfYes,DateofRelapseorProgression:

Data type

text

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

Ifyes,pleasesubmittheLungCarcinomaFirstSite(s)ofProgressionorRelapseForm.

Data type

text

Notice Of New Primary
Description

Notice Of New Primary

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

Hasanewprimarycancerormyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?

Data type

text

If Yes, Date of Diagnosis
Description

IfYes,DateofDiagnosis:

Data type

text

New Primary Site
Description

NewPrimarySite:

Data type

text

Non-protocol Treatment
Description

Non-protocol Treatment

Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
Description

Hasthepatientreceivedanynon-protocolcancertherapy(priortoprogression/relapse)notpreviouslyreported?

Data type

text

If Yes, Date of First Non-Protocol Therapy
Description

IfYes,DateofFirstNon-ProtocolTherapy:

Data type

text

Agents
Description

Agents:

Data type

text

Long Term Toxicity
Description

Long Term Toxicity

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

If Yes, Toxicities and Grades
Description

IfYes,ToxicitiesandGrades:

Data type

text

Notes
Description

Notes

Notes
Description

Notes

Data type

text

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No Instruction available.

1 forms
  1. StudyEvent: S0023 LUNG CARCINOMA FOLLOW UP FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
PatientInitials
Item
Patient Initials (L, F,M)
text
Institution/Affiliate
Item
Institution / Affiliate
text
Physician
Item
Physician
text
GroupName
Item
Group Name (Groups other than SWOG )
text
StudyNo.
Item
Study No. (Groups other than SWOG )
double
Pt.ID
Item
Pt. ID (Groups other than SWOG )
text
Item Group
Vital Status
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Dateoflastcontactordeath:
Item
Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
text
Item Group
Disease Follow Up Status
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)
CL Item
Yes (Yes)
IfYes,DateofLastClinicalAssessment:
Item
If Yes, Date of Last Clinical Assessment
text
Item
Has the patient developed a first relapse or progression that has not been previously reported?
text
CL.3
Code List
Has the patient developed a first relapse or progression that has not been previously reported?
CL Item
No2007229 (No)
CL Item
Yes2007230 (Yes)
IfYes,DateofRelapseorProgression:
Item
If Yes, Date of Relapse or Progression
text
Ifyes,pleasesubmittheLungCarcinomaFirstSite(s)ofProgressionorRelapseForm.
Item
If yes, please submit the Lung Carcinoma First Site(s) of Progression or Relapse Form.
text
Item Group
Notice Of New Primary
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
text
CL.4
Code List
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
CL Item
No2007235 (No)
CL Item
Yes2007236 (Yes)
IfYes,DateofDiagnosis:
Item
If Yes, Date of Diagnosis
text
NewPrimarySite:
Item
New Primary Site
text
Item Group
Non-protocol Treatment
Item
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
text
CL.5
Code List
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
CL Item
No2007241 (No)
CL Item
Yes2007242 (Yes)
IfYes,DateofFirstNon-ProtocolTherapy:
Item
If Yes, Date of First Non-Protocol Therapy
text
Agents:
Item
Agents
text
Item Group
Long Term Toxicity
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.6
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
No2007247 (No)
CL Item
Yes2007248 (Yes)
IfYes,ToxicitiesandGrades:
Item
If Yes, Toxicities and Grades
text
Item Group
Notes
Notes
Item
Notes
text
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