ID

23121

Description

Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix GOG Treatment Completion Form 2059221v3.0 https://clinicaltrials.gov/ct2/show/NCT00064077

Link

https://clinicaltrials.gov/ct2/show/NCT00064077

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 6/24/17 6/24/17 - Martin Dugas
Uploaded on

June 24, 2017

DOI

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License

Creative Commons BY 4.0
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Cervical Cancer Cisplatin NCT00064077 GOG

English

FORM Q0

1 forms  
  1. StudyEvent: GOG Treatment Completion Form
    1. FORM Q0
Header Module
Description

Header Module

Alias
UMLS CUI-1
C1320722
Date form originally completed
Description

Form Completion Date

Data type

date

Measurement units
  • m d y
Alias
UMLS CUI [1]
C1549507
m d y
Date form amended
Description

Form Amendment Date

Data type

date

Measurement units
  • m d y
Alias
UMLS CUI [1,1]
C0680532
UMLS CUI [1,2]
C0011008
m d y
Patient Name, Last
Description

Patient Lastname

Data type

text

Alias
UMLS CUI [1]
C1301584
Patient Name, First
Description

Patient Firstname

Data type

text

Alias
UMLS CUI [1]
C0421447
Patient Study ID
Description

Patient Study ID

Data type

text

Alias
UMLS CUI [1]
C2348585
Participating Group Code
Description

Participating Clinical Study Organization

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS CUI [1]
C2347449
Participating Group Protocol Number
Description

Participating Group Protocol Number

Data type

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C2347449
Participating Patient Study ID
Description

Patient Identifier Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C2347449
Person amending form, last name
Description

Responsible Person Reporting Change

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25364
UMLS CUI [1,1]
C0680532
UMLS CUI [1,2]
C1547383
Person Completing Form, Last Name
Description

Person Completing Form

Data type

text

Alias
UMLS CUI [1]
C3258039
COMMENTS
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Treatment Schedule
Description

Treatment Schedule

Alias
UMLS CUI-1
C0040808
Total number of cycles given
Description

Total Course Number

Data type

integer

Alias
UMLS CUI [1]
C2045831
Last date (any modality of) protocol therapy was given
Description

Treatment End Date

Data type

date

Measurement units
  • m d y
Alias
UMLS CUI [1]
C1531784
m d y
Off-treatment Reason
Description

Off-treatment Reason

Alias
UMLS CUI-1
C1518544
UMLS CUI-2
C0566251
Reason treatment ended (check only one)
Description

Off Treatment Reason

Data type

integer

Alias
UMLS CUI [1,1]
C1518544
UMLS CUI [1,2]
C0566251
Specify toxicity (unnamed)
Description

Toxicity

Data type

text

Alias
UMLS CUI [1]
C0013221
Specify reason (unnamed)
Description

Reason Off-Treatment

Data type

text

Alias
NCI Thesaurus ObjectClass
C25638
NCI Thesaurus ObjectClass-2
C25601
NCI Metathesaurus Property
C0030705
NCI Thesaurus Property
C41341
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1,1]
C1518544
UMLS CUI [1,2]
C0566251
Specify disease
Description

Complicating Disease

Data type

text

Alias
UMLS CUI [1]
C0544688
Will patient receive further treatment?
Description

Further Treatment

Data type

boolean

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1517331
Specify further treatment
Description

Further Treatment, specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25519
NCI Thesaurus Property
C25382
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1517331
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Similar models

FORM Q0

1 forms
  1. StudyEvent: GOG Treatment Completion Form
    1. FORM Q0
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Form Completion Date
Item
Date form originally completed
date
C1549507 (UMLS CUI [1])
Form Amendment Date
Item
Date form amended
date
C0680532 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Patient Lastname
Item
Patient Name, Last
text
C1301584 (UMLS CUI [1])
Patient Firstname
Item
Patient Name, First
text
C0421447 (UMLS CUI [1])
Patient Study ID
Item
Patient Study ID
text
C2348585 (UMLS CUI [1])
Participating Clinical Study Organization
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI [1])
Participating Group Protocol Number
Item
Participating Group Protocol Number
text
C3274381 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Patient Identifier Number
Item
Participating Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Responsible Person Reporting Change
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C0680532 (UMLS CUI [1,1])
C1547383 (UMLS CUI [1,2])
Person Completing Form
Item
Person Completing Form, Last Name
text
C3258039 (UMLS CUI [1])
Comments
Item
COMMENTS
text
C0947611 (UMLS CUI [1])
Item Group
Treatment Schedule
C0040808 (UMLS CUI-1)
Total Course Number
Item
Total number of cycles given
integer
C2045831 (UMLS CUI [1])
Treatment End Date
Item
Last date (any modality of) protocol therapy was given
date
C1531784 (UMLS CUI [1])
Item Group
Off-treatment Reason
C1518544 (UMLS CUI-1)
C0566251 (UMLS CUI-2)
Item
Reason treatment ended (check only one)
integer
C1518544 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
CL.1
Code List
Reason treatment ended (check only one)
CL Item
Routine completion of planned protocol treatment (1)
C0040808 (UMLS CUI-1)
C0205197 (UMLS CUI-2)
CL Item
Disease progression, relapse during active treatment (2)
C0242656 (UMLS CUI-1)
CL Item
Toxicity/side effects/complications (3)
C0877248 (UMLS CUI-1)
CL Item
Patient withdrawal or refusal for reason other than toxicity (4)
C0040809 (UMLS CUI-1)
CL Item
Death after beginning protocol therapy (5)
C0011065 (UMLS CUI-1)
CL Item
Patient off-treatment for other complicating disease (6)
C0009566 (UMLS CUI-1)
CL Item
Other (7)
C0205394 (UMLS CUI-1)
Toxicity
Item
Specify toxicity (unnamed)
text
C0013221 (UMLS CUI [1])
Reason Off-Treatment
Item
Specify reason (unnamed)
text
C25638 (NCI Thesaurus ObjectClass)
C25601 (NCI Thesaurus ObjectClass-2)
C0030705 (NCI Metathesaurus Property)
C41341 (NCI Thesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1518544 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Complicating Disease
Item
Specify disease
text
C0544688 (UMLS CUI [1])
Further Treatment
Item
Will patient receive further treatment?
boolean
C0087111 (UMLS CUI [1,1])
C1517331 (UMLS CUI [1,2])
Further Treatment, specify
Item
Specify further treatment
text
C25685 (NCI Thesaurus ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25519 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
C0087111 (UMLS CUI [1,1])
C1517331 (UMLS CUI [1,2])
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