ID

2243

Beschrijving

LUNG CARCINOMA RADIATION THERAPY 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=9E343E83-5FEB-119F-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E343E83-5FEB-119F-E034-080020C9C0E0

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 08-05-15 08-05-15 - Martin Dugas
Geüploaded op

19 september 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00020709 Registration - LUNG CARCINOMA RADIATION THERAPY FORM - 2031928v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: LUNG CARCINOMA RADIATION THERAPY FORM
    1. No Instruction available.
Unnamed1
Beschrijving

Unnamed1

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

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

PatientInitials

Datatype

text

Social Security No.
Beschrijving

SocialSecurityNo.

Datatype

text

Institution / Affiliate
Beschrijving

Institution/Affiliate

Datatype

text

Physician
Beschrijving

Physician

Datatype

text

Hosp. No.
Beschrijving

Hosp.No.

Datatype

text

Group Name (Groups other than SWOG )
Beschrijving

GroupName

Datatype

text

Study No. (Groups other than SWOG )
Beschrijving

StudyNo.

Datatype

double

Pt. ID (Groups other than SWOG )
Beschrijving

Pt.ID

Datatype

text

Treating Radiation Oncologist
Beschrijving

TreatingRadiationOncologist

Datatype

text

RT Facility
Beschrijving

RTFacility

Datatype

text

RT Facility Code
Beschrijving

RTFacilityCode

Datatype

text

Unnamed2
Beschrijving

Unnamed2

Radiation Therapy Start Date
Beschrijving

RTBeginDate

Datatype

date

RT End Date
Beschrijving

RTEndDate

Datatype

date

Were there any unscheduled interruptions in radiation therapy?
Beschrijving

Werethereanyunscheduledinterruptionsinradiationtherapy?

Datatype

text

If Yes, Specify RT Interruptions Reason
Beschrijving

IfYes,SpecifyRTInterruptionsReason

Datatype

text

Treatment Information
Beschrijving

Treatment Information

Total Dose to Isocenter (cGy)
Beschrijving

TotalDosetoIsocenter

Datatype

text

Total Fractions
Beschrijving

TotalFractions

Datatype

text

Radiation Source
Beschrijving

RadiationSource

Datatype

text

Other, specify
Beschrijving

CytogeneticAnalysis,OtherReason,NoSuccess

Datatype

text

Fractions
Beschrijving

Fractions

Datatype

text

Number of Days
Beschrijving

NumberofDays

Datatype

text

Number of Days
Beschrijving

NumberofDays

Datatype

text

Radiation Energy (MeV)
Beschrijving

RadiationEnergy

Datatype

text

Maximum Dose to Critical Structures
Beschrijving

MaximumDosetoCriticalStructures

Datatype

text

Spinal Cord
Beschrijving

SpinalCord

Datatype

text

Heart
Beschrijving

Heart

Datatype

text

Esophagus
Beschrijving

Esophagus

Datatype

text

Other structures
Beschrijving

TumorExtension,OtherStructures

Datatype

text

Specify
Beschrijving

Specify

Datatype

text

Specify
Beschrijving

Specify

Datatype

text

Specify
Beschrijving

Specify

Datatype

text

Dose (cGy)
Beschrijving

RadiationTherapyDose

Datatype

text

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
Dose (cGy)
Beschrijving

RadiationTherapyDose

Datatype

text

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
%Of Total Lung Receiving>=2000 cGy
Beschrijving

%OfTotalLungReceiving>=2000cGy

Datatype

text

%Of Right Lung Receiving>=2000 cGy
Beschrijving

%OfRightLungReceiving>=2000cGy

Datatype

text

Primary Tumor location
Beschrijving

PrimaryTumorlocation

Datatype

text

%Of Left Lung Receiving>=2000 cGy
Beschrijving

%OfLeftLungReceiving>=2000cGy

Datatype

text

Unnamed4
Beschrijving

Unnamed4

Form completed by
Beschrijving

Formcompletedby

Datatype

text

Facility
Beschrijving

Facility

Datatype

text

Telephone Number
Beschrijving

TelephoneNumber

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C25395
UMLS 2011AA ValueDomain
C0039457
Date
Beschrijving

Date

Datatype

text

Unnamed5
Beschrijving

Unnamed5

Radiation Oncologist's Signature
Beschrijving

RadiationOncologyPhysicianSignatureText

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C17833
UMLS 2011AA ObjectClass
C1514693
Notes
Beschrijving

Notes

Notes
Beschrijving

Notes

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: LUNG CARCINOMA RADIATION THERAPY FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
SocialSecurityNo.
Item
Social Security No.
text
Institution/Affiliate
Item
Institution / Affiliate
text
Physician
Item
Physician
text
Hosp.No.
Item
Hosp. No.
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
TreatingRadiationOncologist
Item
Treating Radiation Oncologist
text
RTFacility
Item
RT Facility
text
RTFacilityCode
Item
RT Facility Code
text
Item Group
Unnamed2
RTBeginDate
Item
Radiation Therapy Start Date
date
RTEndDate
Item
RT End Date
date
Item
Were there any unscheduled interruptions in radiation therapy?
text
CL.1
Code List
Were there any unscheduled interruptions in radiation therapy?
CL Item
Yes (Yes)
CL Item
No (No)
IfYes,SpecifyRTInterruptionsReason
Item
If Yes, Specify RT Interruptions Reason
text
Item Group
Treatment Information
TotalDosetoIsocenter
Item
Total Dose to Isocenter (cGy)
text
TotalFractions
Item
Total Fractions
text
Item
Radiation Source
text
CL.2
Code List
Radiation Source
CL Item
Co_60_2005542 (Co 60)
CL Item
Megavoltage_2005543 (Megavoltage)
CL Item
Electron_2005544 (Electron)
CL Item
Combination_2005545 (Combination)
CL Item
Other_specify_2005546 (Other, specify)
CytogeneticAnalysis,OtherReason,NoSuccess
Item
Other, specify
text
Fractions
Item
Fractions
text
NumberofDays
Item
Number of Days
text
NumberofDays
Item
Number of Days
text
Item
Radiation Energy (MeV)
text
CL.4
Code List
Radiation Energy (MeV)
CL Item
P98not_applicable2005561 (98=not applicable)
MaximumDosetoCriticalStructures
Item
Maximum Dose to Critical Structures
text
SpinalCord
Item
Spinal Cord
text
Heart
Item
Heart
text
Esophagus
Item
Esophagus
text
TumorExtension,OtherStructures
Item
Other structures
text
Specify
Item
Specify
text
Specify
Item
Specify
text
Specify
Item
Specify
text
RadiationTherapyDose
Item
Dose (cGy)
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
RadiationTherapyDose
Item
Dose (cGy)
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
%OfTotalLungReceiving>=2000cGy
Item
%Of Total Lung Receiving>=2000 cGy
text
%OfRightLungReceiving>=2000cGy
Item
%Of Right Lung Receiving>=2000 cGy
text
Item
Primary Tumor location
text
CL.5
Code List
Primary Tumor location
CL Item
Left_lung2005574 (Left lung)
CL Item
Right_lung2005575 (Right lung)
%OfLeftLungReceiving>=2000cGy
Item
%Of Left Lung Receiving>=2000 cGy
text
Item Group
Unnamed4
Formcompletedby
Item
Form completed by
text
Facility
Item
Facility
text
TelephoneNumber
Item
Telephone Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25395 (NCI Thesaurus ValueDomain)
C0039457 (UMLS 2011AA ValueDomain)
Date
Item
Date
text
Item Group
Unnamed5
RadiationOncologyPhysicianSignatureText
Item
Radiation Oncologist's Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C17833 (NCI Thesaurus ObjectClass)
C1514693 (UMLS 2011AA ObjectClass)
Item Group
Notes
Notes
Item
Notes
text
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