ID

2259

Beskrivning

Form 5M - Minimal Follow-Up Report Gefitinib in Treating Patients With Non-Small Cell Lung Cancer That Has Been Surgically Removed Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6FFB989-6864-715F-E034-0003BA0B1A09

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6FFB989-6864-715F-E034-0003BA0B1A09

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

19 september 2012

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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Lung Cancer NCT00049543 Follow-Up - Form 5M - Minimal Follow-Up Report - 2050474v3.0

No Instruction available.

  1. StudyEvent: Form 5M - Minimal Follow-Up Report
    1. No Instruction available.
Patient Information
Beskrivning

Patient Information

Patient Study ID, Coordinating Group
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Patient Initials (first - middle - last)
Beskrivning

PatientInitialsName

Datatyp

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
Patient Medical Record Number
Beskrivning

PatientMedicalRecordNumber

Datatyp

text

Institution Name
Beskrivning

InstitutionName

Datatyp

text

Registered Investigator (NCI Investigator #)
Beskrivning

RegisteredInvestigator

Datatyp

text

Status
Beskrivning

Status

Patient's Vital Status
Beskrivning

Patient'sVitalStatus

Datatyp

text

Primary Cause of Death
Beskrivning

DeathReason

Datatyp

text

Describe cause of death
Beskrivning

DeathReason,Specify

Datatyp

text

Date of Last Contact or Death (yyyy mmm dd)
Beskrivning

DeathDate/LastContactDate

Datatyp

date

Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
Beskrivning

CancerFollow-upStatusInd

Datatyp

text

Date of Last Clinical Assessment (yyyy mmm dd)
Beskrivning

CancerFollow-upStatusDate

Datatyp

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? (* submit Form 9 Relapse Report if this is the first evidence of recurrence)
Beskrivning

ProgressionInd

Datatyp

text

Date of Progression (yyyy mmm dd)
Beskrivning

ProgressionDate

Datatyp

date

Other Malignancies Or Myelodysplastic Syndrome
Beskrivning

Other Malignancies Or Myelodysplastic Syndrome

Has a new primary cancer or MDS been diagnosed that was not previously reported?
Beskrivning

NewPrimaryCancerInd

Datatyp

text

Date of diagnosis (yyyy mmm dd)
Beskrivning

NewPrimaryCancerDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Malignancy Type
Beskrivning

NewPrimaryMalignancyType

Datatyp

text

Site(s) of New Primary
Beskrivning

NewPrimarySite

Datatyp

text

Describe
Beskrivning

NewPrimaryDetail

Datatyp

text

Ncic Ctg Use Only
Beskrivning

Ncic Ctg Use Only

Logged
Beskrivning

LoggedEntryInitials

Datatyp

text

Unnamed (Logged Date)
Beskrivning

LoggedEntryDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
RA
Beskrivning

RegulatoryAffairsReviewInitials

Datatyp

text

Unnamed (RA Date)
Beskrivning

RegulatoryAffairsReviewDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Study Coord
Beskrivning

CoordinatorReviewInitials

Datatyp

text

Unnamed (Coord Date)
Beskrivning

CoordinatorReviewDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Phy
Beskrivning

PhysicianReviewInitials

Datatyp

text

Data Ent'd
Beskrivning

DataEntryInitials

Datatyp

text

Verified
Beskrivning

DataVerificationInitials

Datatyp

text

Unnamed1
Beskrivning

Unnamed1

Patient Study ID, Coordinating Group
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Patient Initials (first - middle - last)
Beskrivning

PatientInitialsName

Datatyp

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
Comments
Beskrivning

Comments

COMMENTS
Beskrivning

Comments

Datatyp

text

Investigator Signature
Beskrivning

Investigator Signature

Investigator Signature
Beskrivning

InvestigatorSignature

Datatyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Beskrivning

PersonCompletingForm,LastName

Datatyp

text

Person Completing Form, First Name
Beskrivning

PersonCompletingForm,FirstName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Beskrivning

FormCompletionDate,Original

Datatyp

date

Ccrr Module For Form 5m - Minimal Follow-up Report
Beskrivning

Ccrr Module For Form 5m - Minimal Follow-up Report

Similar models

No Instruction available.

  1. StudyEvent: Form 5M - Minimal Follow-Up Report
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientInitialsName
Item
Patient Initials (first - middle - last)
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)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Status
Item
Patient's Vital Status
text
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item
Primary Cause of Death
text
Code List
Primary Cause of Death
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Other Cause, Specify (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Describe cause of death
text
DeathDate/LastContactDate
Item
Date of Last Contact or Death (yyyy mmm dd)
date
Item
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
text
Code List
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment (yyyy mmm dd)
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? (* submit Form 9 Relapse Report if this is the first evidence of recurrence)
text
Code List
Has the patient developed a first progression (or relapse) that has not been previously reported? (* submit Form 9 Relapse Report if this is the first evidence of recurrence)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
ProgressionDate
Item
Date of Progression (yyyy mmm dd)
date
Item Group
Other Malignancies Or Myelodysplastic Syndrome
Item
Has a new primary cancer or MDS been diagnosed that was not previously reported?
text
Code List
Has a new primary cancer or MDS been diagnosed that was not previously reported?
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 (yyyy mmm dd)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimaryMalignancyType
Item
Malignancy Type
text
NewPrimarySite
Item
Site(s) of New Primary
text
NewPrimaryDetail
Item
Describe
text
Item Group
Ncic Ctg Use Only
LoggedEntryInitials
Item
Logged
text
LoggedEntryDate
Item
Unnamed (Logged Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
RegulatoryAffairsReviewInitials
Item
RA
text
RegulatoryAffairsReviewDate
Item
Unnamed (RA Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CoordinatorReviewInitials
Item
Study Coord
text
CoordinatorReviewDate
Item
Unnamed (Coord Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhysicianReviewInitials
Item
Phy
text
DataEntryInitials
Item
Data Ent'd
text
DataVerificationInitials
Item
Verified
text
Item Group
Unnamed1
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientInitialsName
Item
Patient Initials (first - middle - last)
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)
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Ccrr Module For Form 5m - Minimal Follow-up Report

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