ID

2222

Descrição

Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT Radiation Therapy in Preventing CNS Metastases in Patients With Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-7094-05D5-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-7094-05D5-E034-080020C9C0E0

Palavras-chave

  1. 19/09/2012 19/09/2012 -
  2. 28/05/2015 28/05/2015 -
  3. 03/06/2015 03/06/2015 -
  4. 20/09/2021 20/09/2021 -
Transferido a

19 de setembro de 2012

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy

Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

Lung Cancer NCT00048997 Treatment - Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT - 2033093v3.0

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT
    1. No Instruction available.
Unnamed1
Descrição

Unnamed1

Institution
Descrição

InstitutionName

Tipo de dados

text

Institution #
Descrição

NCIInstitutionNumber

Tipo de dados

text

Patient Name
Descrição

PatientName

Tipo de dados

text

Case #
Descrição

Case#

Tipo de dados

text

Patient ID #
Descrição

PatientID#

Tipo de dados

text

Unnamed2
Descrição

Unnamed2

DATE OF LAST CLINICAL ASSESSMENT
Descrição

CancerFollow-upStatusDate

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
PATIENT'S VITAL STATUS
Descrição

Patient'sVitalStatus

Tipo de dados

text

LAST CONTACT DATE / DEATH DATE
Descrição

DeathDate/LastContactDate

Tipo de dados

date

CAUSE OF DEATH
Descrição

DeathReason

Tipo de dados

text

Cause of death, other specify
Descrição

DeathReason,Specify

Tipo de dados

text

PERFORMANCE STATUS (ZUBROD)
Descrição

PerformanceStatus

Tipo de dados

text

HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (Complete Q6 A and B)
Descrição

ProgressionInd

Tipo de dados

text

Sites of progression, lung
Descrição

Sitesofprogression,lung

Tipo de dados

text

Sites of progression, Lymph nodes (distant)
Descrição

Sitesofprogression,Lymphnodes(distant)

Tipo de dados

text

Sites of progression, pleural
Descrição

Sitesofprogression,pleural

Tipo de dados

text

Sites of progression, adrenals
Descrição

Sitesofprogression,adrenals

Tipo de dados

text

Sites of progression, liver
Descrição

Sitesofprogression,liver

Tipo de dados

text

Sites of progression, bone
Descrição

Sitesofprogression,bone

Tipo de dados

text

Sites of progression, CNS (Brain)
Descrição

Sitesofprogression,CNS(Brain)

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25331
NCI Thesaurus ObjectClass
C12438
UMLS 2011AA ObjectClass
C0927232
CNS (Brain) Date
Descrição

ProgressionDate

Tipo de dados

date

Sites of progression, Other Specify
Descrição

Sitesofprogression,OtherSpecify

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C17649
UMLS 2011AA ValueDomain
C0205394
Site of progression, other specify
Descrição

ProgressionSite,Other

Tipo de dados

text

PROGRESSION ASSESSMENT
Descrição

ProgressionAssessmentMethod

Tipo de dados

double

HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?
Descrição

NewPrimaryCancerInd

Tipo de dados

text

NEW PRIMARY SITE
Descrição

NewPrimarySite

Tipo de dados

text

NEW PRIMARY HISTOLOGIC TYPE
Descrição

NewPrimary,HistologicType

Tipo de dados

text

DATE OF DIAGNOSIS
Descrição

NewPrimaryCancerDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
Descrição

Non-ProtocolTherapyInd

Tipo de dados

text

Non-Protocol RT
Descrição

Non-ProtocolRTInd

Tipo de dados

text

Non-Protocol Surgery
Descrição

Non-protocolSurgeryPerformedInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
Non-Protocol Chemotherapy
Descrição

Non-ProtocolChemotherapyInd

Tipo de dados

text

Other Non-Protocol therapy
Descrição

OtherNon-ProtocolTherapyInd

Tipo de dados

text

Specify other
Descrição

OtherNon-ProtocolTherapyName

Tipo de dados

text

Date of first non-protocol therapy
Descrição

Non-ProtocolTherapyDate,First

Tipo de dados

date

Date of first non-protocol therapy
Descrição

Non-ProtocolTherapyDate,First

Tipo de dados

date

Date of first non-protocol therapy
Descrição

Non-ProtocolTherapyDate,First

Tipo de dados

date

Date of first non-protocol therapy
Descrição

Non-ProtocolTherapyDate,First

Tipo de dados

date

Revised
Descrição

AmendedDataInd

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
IMT CODE TOXICITY CODE BASED ON CTEP TOXICITY TERM
Descrição

IMTCODETOXICITYCODEBASEDONCTEPTOXICITYTERM

Tipo de dados

text

TERM
Descrição

CTCAdverseEventTerm

Tipo de dados

text

GENERAL TOXICITY CATEGORY
Descrição

CTCAdverseEventCategory

Tipo de dados

text

SEVERITY GRADE
Descrição

CTCAdverseEventGrade

Tipo de dados

text

DATE OF 1ST OCCURRENCE OF GRADE=>3
Descrição

DATEOF1STOCCURRENCEOFGRADE=>3

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
ATTRIBUTION
Descrição

CTCAdverseEventAttributionCode

Tipo de dados

text

DESCRIPTION
Descrição

DESCRIPTION

Tipo de dados

text

HQ Use
Descrição

HQUse

Tipo de dados

text

Comments
Descrição

Comments

Comments
Descrição

Comments

Tipo de dados

text

Unnamed3
Descrição

Unnamed3

Signature of Person Completing This Form
Descrição

SignatureofPersonCompletingThisForm

Tipo de dados

text

Date
Descrição

FormCompletionDate,Original

Tipo de dados

date

Similar models

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Initial Follow-up Form Phase III Lung Prophylactic Cranial RT
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Unnamed1
InstitutionName
Item
Institution
text
NCIInstitutionNumber
Item
Institution #
text
PatientName
Item
Patient Name
text
Case#
Item
Case #
text
PatientID#
Item
Patient ID #
text
Item Group
Unnamed2
CancerFollow-upStatusDate
Item
DATE OF LAST CLINICAL ASSESSMENT
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
PATIENT'S VITAL STATUS
text
Code List
PATIENT'S VITAL STATUS
CL Item
Alive (Alive)
CL Item
Dead (Dead)
CL Item
Lost (Lost)
CL Item
Unknown (Unknown)
DeathDate/LastContactDate
Item
LAST CONTACT DATE / DEATH DATE
date
Item
CAUSE OF DEATH
text
Code List
CAUSE OF DEATH
CL Item
Related to or probably related to the cancer under study (Related to or probably related to the cancer under study)
CL Item
(whether local, regional, or distant) ((whether local, regional, or distant))
CL Item
Related to or probably related to a second primary tumor (Related to or probably related to a second primary tumor)
CL Item
Related to or probably related to complications of protocol treatment (Related to or probably related to complications of protocol treatment)
CL Item
(explain in COMMENTS, requires a grade 5 toxicity code) ((explain in COMMENTS, requires a grade 5 toxicity code))
CL Item
Related to or probably related to complications of other treatment (Related to or probably related to complications of other treatment)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Cause of death, other specify
text
PerformanceStatus
Item
PERFORMANCE STATUS (ZUBROD)
text
Item
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (Complete Q6 A and B)
text
Code List
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (Complete Q6 A and B)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Sites of progression, lung
text
Code List
Sites of progression, lung
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, Lymph nodes (distant)
text
Code List
Sites of progression, Lymph nodes (distant)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, pleural
text
Code List
Sites of progression, pleural
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, adrenals
text
Code List
Sites of progression, adrenals
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, liver
text
Code List
Sites of progression, liver
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, bone
text
Code List
Sites of progression, bone
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, CNS (Brain)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25331 (NCI Thesaurus Property)
C12438 (NCI Thesaurus ObjectClass)
C0927232 (UMLS 2011AA ObjectClass)
Code List
Sites of progression, CNS (Brain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
ProgressionDate
Item
CNS (Brain) Date
date
Item
Sites of progression, Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
Code List
Sites of progression, Other Specify
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
ProgressionSite,Other
Item
Site of progression, other specify
text
Item
PROGRESSION ASSESSMENT
double
Code List
PROGRESSION ASSESSMENT
CL Item
Physical Exam (Physical Exam)
CL Item
Radiographic (Radiographic)
CL Item
Pathologic (Pathologic)
Item
HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?
text
Code List
HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED 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)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
NewPrimarySite
Item
NEW PRIMARY SITE
text
NewPrimary,HistologicType
Item
NEW PRIMARY HISTOLOGIC TYPE
text
NewPrimaryCancerDate
Item
DATE OF DIAGNOSIS
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
text
Code List
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol RT
text
Code List
Non-Protocol RT
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol Surgery
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
Code List
Non-Protocol Surgery
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol Chemotherapy
text
Code List
Non-Protocol Chemotherapy
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Other Non-Protocol therapy
text
Code List
Other Non-Protocol therapy
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
OtherNon-ProtocolTherapyName
Item
Specify other
text
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
AmendedDataInd
Item
Revised
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
IMTCODETOXICITYCODEBASEDONCTEPTOXICITYTERM
Item
IMT CODE TOXICITY CODE BASED ON CTEP TOXICITY TERM
text
CTCAdverseEventTerm
Item
TERM
text
Item
GENERAL TOXICITY CATEGORY
text
Code List
GENERAL TOXICITY CATEGORY
CL Item
Allergy / Immunology (Allergy / Immunology)
CL Item
Auditory/Hearing (Auditory/Hearing)
CL Item
Blood/Bone marrow (Blood/Bone marrow)
CL Item
Cardiovascular (Arrhythmia) (Cardiovascular (Arrhythmia))
CL Item
Cardiovascular (General) (Cardiovascular (General))
CL Item
Coagulation (Coagulation)
CL Item
Constitutional Symptoms (Constitutional Symptoms)
CL Item
Dermatology/Skin (Dermatology/Skin)
CL Item
Endocrine (Endocrine)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Hemorrhage (Hemorrhage)
CL Item
Hepatic (Hepatic)
CL Item
Infection/Febrile Neutropenia (Infection/Febrile Neutropenia)
CL Item
Lymphatics (Lymphatics)
CL Item
Metabolic/Laboratory (Metabolic/Laboratory)
CL Item
Musculoskeletal (Musculoskeletal)
CL Item
Neurology (Neurology)
CL Item
Ocular/Visual (Ocular/Visual)
CL Item
Pain (Pain)
CL Item
Pulmonary (Pulmonary)
CL Item
Renal/Genitourinary (Renal/Genitourinary)
CL Item
Second Malignancy (Second Malignancy)
CL Item
Sexual/Reproductive Function (Sexual/Reproductive Function)
CL Item
Syndromes (Syndromes)
CTCAdverseEventGrade
Item
SEVERITY GRADE
text
DATEOF1STOCCURRENCEOFGRADE=>3
Item
DATE OF 1ST OCCURRENCE OF GRADE=>3
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
ATTRIBUTION
text
Code List
ATTRIBUTION
CL Item
Radiotherapy only (Brain) (Radiotherapy only (Brain))
CL Item
Other cause, specify in "Description" (Other cause, specify in "Description")
CL Item
Unknown (Unknown)
DESCRIPTION
Item
DESCRIPTION
text
HQUse
Item
HQ Use
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Unnamed3
SignatureofPersonCompletingThisForm
Item
Signature of Person Completing This Form
text
FormCompletionDate,Original
Item
Date
date

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

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