ID

23034

Beschrijving

IBCSG Long Term Follow-Up Second Non-Breast Malignancy (18-LTF-SM) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C7665-5F80-48C7-E040-BB89AD436937

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C7665-5F80-48C7-E040-BB89AD436937

Trefwoorden

  1. 26-08-12 26-08-12 -
  2. 20-06-17 20-06-17 - Martin Dugas
Geüploaded op

20 juni 2017

DOI

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Licentie

Creative Commons BY-NC 3.0

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IBCSG Long Term Follow-Up Second Non-Breast Malignancy (18-LTF-SM)

Complete this form for patients who have a proven second (non-breast) malignancy. Use minus one (-1) to indicate an answer is unknown, unobtainable or not done

Header Module
Beschrijving

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Beschrijving

Hospital Admission Ordinal Number

Datatype

integer

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

Patient International Breast Cancer Study Group Identifier Number

Datatype

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.
Beschrijving

Protocol International Breast Cancer Study Group Identifier Number

Datatype

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.
Beschrijving

Randomization Number

Datatype

text

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

Institution Identifier Number

Datatype

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
Beschrijving

Institution Name

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
UMLS CUI [1]
C1301943
Second Non-breast Malignancy
Beschrijving

Second Non-breast Malignancy

Alias
UMLS CUI-1
C0085183
Specify site (non-breast)
Beschrijving

Cancer Site

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C25586
NCI Thesaurus Property
C25341
NCI Thesaurus ObjectClass-2
C9305
UMLS CUI [1]
C3173298
Specify type (non-breast)
Beschrijving

Primary Tumor Diagnosis

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C3262
NCI Thesaurus ObjectClass-2
C25251
NCI Thesaurus Property
C15220
UMLS CUI [1,1]
C0677930
UMLS CUI [1,2]
C0011900
Date of Diagnosis of Second Primary Cancer (non-breast day month year)
Beschrijving

Second Primary Neoplasm Diagnosis Date

Datatype

date

Alias
NCI Thesaurus ObjectClass
C3262
NCI Thesaurus ObjectClass-2
C25251
NCI Thesaurus ObjectClass-3
C25666
NCI Thesaurus Property
C15220
NCI Thesaurus ValueDomain
C25164
UMLS CUI [1,1]
C0085183
UMLS CUI [1,2]
C2316983
Footer Module
Beschrijving

Footer Module

Alias
UMLS CUI-1
C2825232
Investigator/Designee Signature
Beschrijving

Investigator Signature

Datatype

text

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

Investigator Signature Date

Datatype

date

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

Similar models

Complete this form for patients who have a proven second (non-breast) malignancy. Use minus one (-1) to indicate an answer is unknown, unobtainable or not done

Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
Second Non-breast Malignancy
C0085183 (UMLS CUI-1)
Cancer Site
Item
Specify site (non-breast)
text
C25704 (NCI Thesaurus ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C25341 (NCI Thesaurus Property)
C9305 (NCI Thesaurus ObjectClass-2)
C3173298 (UMLS CUI [1])
Primary Tumor Diagnosis
Item
Specify type (non-breast)
text
C25704 (NCI Thesaurus ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C25251 (NCI Thesaurus ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0677930 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Second Primary Neoplasm Diagnosis Date
Item
Date of Diagnosis of Second Primary Cancer (non-breast day month year)
date
C3262 (NCI Thesaurus ObjectClass)
C25251 (NCI Thesaurus ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C15220 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C0085183 (UMLS CUI [1,1])
C2316983 (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
Investigator Signature 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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