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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

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Versions (2)
  1. 8/26/12 8/26/12 -
  2. 6/12/17 6/12/17 - Martin Dugas
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June 12, 2017

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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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