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])
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
Reason treatment ended (check only one)
integer
C1518544 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
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])