ID

22839

Description

IBCSG Long Term Follow-Up Death Form (18-LTF-Death) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C95-8540-E040-BB89AD4303DD

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C95-8540-E040-BB89AD4303DD

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 6/12/17 6/12/17 - Martin Dugas
Uploaded on

June 12, 2017

DOI

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License

Creative Commons BY-NC 3.0
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IBCSG Long Term Follow-Up Death Form (18-LTF-Death)

English

Instructions: This form is to be completed if the patient died during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done

1 forms  
Header Module
Description

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Description

Hospital Admission Ordinal Number

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI [1]
C1549755
IBCSG Patient ID
Description

Patient International Breast Cancer Study Group Identifier Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25530
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C1512890
IBCSG Study No.
Description

Protocol International Breast Cancer Study Group Identifier Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25530
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C1512890
Randomization No.
Description

Randomization Number

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25364
NCI Thesaurus Property
C25196
UMLS CUI [1]
C2986235
Institution Code Number
Description

Institution Identifier Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus Property
C25364
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0805701
Institution Name
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
UMLS CUI [1]
C1301943
Long Term Follow-up Death
Description

Long Term Follow-up Death

Alias
UMLS CUI-1
C1517942
Date of Death
Description

Death Documented Date

Data type

date

Measurement units
  • day month year
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C28554
NCI Thesaurus Property
C25356
UMLS CUI [1]
C1148348
day month year
Disease status at time of death (or last known report)
Description

Death Contributing Symptom Type

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C28554
NCI Thesaurus Property
C4876
NCI Metathesaurus Property
CL317017
UMLS CUI [1,1]
C0011065
UMLS CUI [1,2]
C1457887
Primary cause of death
Description

Breast Cancer Patient Death Reason

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C28554
NCI Metathesaurus ObjectClass
C0006142
UMLS CUI [1]
C0007465
Other cause of death
Description

specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C28554
NCI Metathesaurus ObjectClass
C0006142
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0007465
Footer Module
Description

Footer Module

Alias
UMLS CUI-1
C2825232
Investigator/Designee Signature
Description

Investigator Signature

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
NCI Thesaurus Property-2
C25479
UMLS CUI [1]
C2346576
Date
Description

Investigator Signature Date

Data type

date

Measurement units
  • day month year
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C25678
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C17089
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
day month year
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Similar models

Instructions: This form is to be completed if the patient died during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Hospital Admission Ordinal Number
Item
Visit number
integer
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI [1])
Patient International Breast Cancer Study Group Identifier Number
Item
IBCSG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25530 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI [1,1])
C1512890 (UMLS CUI [1,2])
Protocol International Breast Cancer Study Group Identifier Number
Item
IBCSG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25530 (NCI Thesaurus Property-2)
C3274381 (UMLS CUI [1,1])
C1512890 (UMLS CUI [1,2])
Randomization Number
Item
Randomization No.
text
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus ValueDomain)
C25196 (NCI Thesaurus Property)
C2986235 (UMLS CUI [1])
Institution Identifier Number
Item
Institution Code Number
text
C25337 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI [1])
Item Group
Long Term Follow-up Death
C1517942 (UMLS CUI-1)
Death Documented Date
Item
Date of Death
date
C25164 (NCI Thesaurus ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C25356 (NCI Thesaurus Property)
C1148348 (UMLS CUI [1])
Item
Disease status at time of death (or last known report)
integer
C25284 (NCI Thesaurus ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C4876 (NCI Thesaurus Property)
CL317017 (NCI Metathesaurus Property)
C0011065 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
CL.1
Code List
Disease status at time of death (or last known report)
CL Item
No Recurrence Or Second Non-breast Primary Malignancy (1)
C0730528 (UMLS CUI-1)
CL Item
Local Recurrence (2)
C0027643 (UMLS CUI-1)
CL Item
Regional Recurrence (3)
C0521158 (UMLS CUI-1)
C0205147 (UMLS CUI-2)
CL Item
Distant Metastasis (4)
C1275402 (UMLS CUI-1)
Item
Primary cause of death
integer
C25638 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C28554 (NCI Thesaurus Property)
C0006142 (NCI Metathesaurus ObjectClass)
C0007465 (UMLS CUI [1])
CL.2
Code List
Primary cause of death
CL Item
Progression Of Underlying Breast Cancer (1)
C0178874 (UMLS CUI-1)
CL Item
Endometrial Cancer (2)
C0476089 (UMLS CUI-1)
CL Item
Myocardial Infarction (3)
C0027051 (UMLS CUI-1)
CL Item
Stroke (4)
C0038454 (UMLS CUI-1)
CL Item
Thromboembolic Event (5)
C0040038 (UMLS CUI-1)
CL Item
Other Cause (6)
C0205394 (UMLS CUI-1)
C0007465 (UMLS CUI-2)
CL Item
Cause Unknown (7)
C0277589 (UMLS CUI-1)
CL Item
Second Non-breast Primary Malignancy (8)
C3266877 (UMLS CUI-1)
Breast Cancer Patient Death Specify
Item
Other cause of death
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C28554 (NCI Thesaurus Property)
C0006142 (NCI Metathesaurus ObjectClass)
C0205394 (UMLS CUI [1,1])
C0007465 (UMLS CUI [1,2])
Item Group
Footer Module
C2825232 (UMLS CUI-1)
Investigator Signature
Item
Investigator/Designee Signature
text
C25704 (NCI Thesaurus ValueDomain)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C25479 (NCI Thesaurus Property-2)
C2346576 (UMLS CUI [1])
Investigator Signature Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C25678 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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