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2317

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ACOSOG-Z4099 Active Monitoring RECIST Measurement Form (Arm 2) Surgery With or Without Internal Radiation Therapy Compared With Stereotactic Body Radiation Therapy in Treating Patients With High-Risk Stage I Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9815654D-3AFA-EB3D-E040-BB89AD437C70

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9815654D-3AFA-EB3D-E040-BB89AD437C70

Nyckelord

Versioner (2)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

19 september 2012

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Creative Commons BY-NC 3.0 Legacy
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    Lung Cancer NCT01336894 Response - ACOSOG-Z4099 Active Monitoring RECIST Measurement Form (Arm 2) - 3178204v1.0

    Engelsk

    ALL ITEMS MUST BE COMPLETED

    1 Formulär  
    1. StudyEvent: ACOSOG-Z4099 Active Monitoring RECIST Measurement Form (Arm 2)
      1. ALL ITEMS MUST BE COMPLETED
    Header Module
    Beskrivning

    Header Module

    Protocol Number
    Beskrivning

    ProtocolACOSOGIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C19712
    UMLS 2011AA Property
    C1515944
    Patient ID
    Beskrivning

    PatientCoordinatingIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25462
    UMLS 2011AA Property
    C0700114
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Initials (L F M)
    Beskrivning

    PatientInitialsName

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25536
    UMLS 2011AA Property
    C1555582
    Institution Number
    Beskrivning

    InstitutionIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Institution
    Beskrivning

    InstitutionName

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Are data amended (check one if data amended, please circle in red when using paper forms)
    Beskrivning

    DataAmendedInd-3

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Visit
    Beskrivning

    Visit

    Visit (check one)
    Beskrivning

    AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ObjectClass
    C19712
    UMLS 2011AA ObjectClass
    C1515944
    NCI Thesaurus ObjectClass
    C25716
    UMLS 2011AA ObjectClass
    C0545082
    Overall Response Status
    Beskrivning

    Overall Response Status

    Overall Response Status at This Assessment (check one)
    Beskrivning

    OverallTumorResponseType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C25605
    UMLS 2011AA ObjectClass
    C1561607
    NCI Thesaurus Property
    C25755
    UMLS 2011AA Property
    C0871261
    Was the appearance of any new lesions documented (If PD: check one NOTE: If PD is selected for Overall Response Status, and Yes is selected for "Was the appearance of any new lesions documented" end form)
    Beskrivning

    NewLesionAppearanceInd-2

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C3824
    UMLS 2011AA ObjectClass
    C0221198
    NCI Thesaurus ObjectClass
    C25586
    UMLS 2011AA ObjectClass
    C0205314
    NCI Thesaurus Property
    C25377
    UMLS 2011AA Property
    C0700364
    Overall Response Status
    Beskrivning

    Overall Response Status

    Assessment date (dd MMM yyyy Assessment date is the date reflecting type of assessment, not the physician interpretation date. If tumor measurements are not required this cycle per Section 4.0, Assessment Date is the date the patient was evaluated )
    Beskrivning

    AssessmentPerformedDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Non-nodal target lesion site(s) (Primary Tumor)
    Beskrivning

    NonNodalTargetLesionPresentSite

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C3824
    UMLS 2011AA ObjectClass
    C0221198
    NCI Thesaurus ObjectClass
    C25594
    UMLS 2011AA ObjectClass
    C1518422
    NCI Thesaurus ObjectClass
    C25323
    UMLS 2011AA ObjectClass
    C0443268
    NCI Thesaurus ObjectClass
    C25702
    UMLS 2011AA ObjectClass
    C1521840
    NCI Thesaurus Property
    C25626
    UMLS 2011AA Property
    C0150312
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    Method of Evaluation
    Beskrivning

    AssessmentMethodType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C20989
    UMLS 2011AA ObjectClass
    C0031809
    NCI Thesaurus Property
    C16847
    UMLS 2011AA Property
    C0449851
    Non-Nodal Longest Diameter of Lesion(s) (Primary Tumor cm)
    Beskrivning

    NegationNodalTargetLesionLongestDiameterMeasurement

    Datatyp

    double

    Måttenheter
    • cm
    Alias
    NCI Thesaurus ObjectClass
    C3824
    UMLS 2011AA ObjectClass
    C0221198
    NCI Thesaurus ObjectClass
    C25594
    UMLS 2011AA ObjectClass
    C1518422
    NCI Thesaurus ObjectClass
    C25323
    UMLS 2011AA ObjectClass
    C0443268
    NCI Thesaurus ObjectClass
    C25702
    UMLS 2011AA ObjectClass
    C1521840
    NCI Thesaurus Property
    C25285
    UMLS 2011AA Property
    C1301886
    NCI Thesaurus Property
    C25558
    UMLS 2011AA Property
    C1522425
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ValueDomain
    C25285
    UMLS 2011AA ValueDomain
    C1301886
    cm
    Tillbaka till toppen

    Similar models

    ALL ITEMS MUST BE COMPLETED

    1 Formulär
    1. StudyEvent: ACOSOG-Z4099 Active Monitoring RECIST Measurement Form (Arm 2)
      1. ALL ITEMS MUST BE COMPLETED
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Header Module
    ProtocolACOSOGIdentifierNumber
    Item
    Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C19712 (NCI Thesaurus Property)
    C1515944 (UMLS 2011AA Property)
    PatientCoordinatingIdentifierNumber
    Item
    Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25462 (NCI Thesaurus Property)
    C0700114 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientInitialsName
    Item
    Patient Initials (L F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    InstitutionIdentifierNumber
    Item
    Institution Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    InstitutionName
    Item
    Institution
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Item
    Are data amended (check one if data amended, please circle in red when using paper forms)
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    CL.1
    Code List
    Are data amended (check one if data amended, please circle in red when using paper forms)
    CL Item
    Yes (yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (no)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Visit
    Item
    Visit (check one)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C19712 (NCI Thesaurus ObjectClass)
    C1515944 (UMLS 2011AA ObjectClass)
    C25716 (NCI Thesaurus ObjectClass)
    C0545082 (UMLS 2011AA ObjectClass)
    CL.2
    Code List
    Visit (check one)
    CL Item
    4 Weeks After Surgery/completion Of Stereotactic Body Radiation Therapy (4 weeks after surgery/completion of SBRT)
    CL Item
    3 Months After Completion Of Stereotactic Body Radiation Therapy (3 months after completion of SBRT)
    CL Item
    6 Months After Completion Of Stereotactic Body Radiation Therapy (6 months after completion of SBRT)
    CL Item
    9 Months After Completion Of Stereotactic Body Radiation Therapy (9 months after completion of SBRT)
    CL Item
    12 Months After Completion Of Stereotactic Body Radiation Therapy (12 months after completion of SBRT)
    Item Group
    Overall Response Status
    Item
    Overall Response Status at This Assessment (check one)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C25605 (NCI Thesaurus ObjectClass)
    C1561607 (UMLS 2011AA ObjectClass)
    C25755 (NCI Thesaurus Property)
    C0871261 (UMLS 2011AA Property)
    CL.3
    Code List
    Overall Response Status at This Assessment (check one)
    CL Item
    Not Evaluated (Not evaluated)
    CL Item
    Complete Response (CR)
    CL Item
    Partial Response (PR)
    C18212 (NCI Thesaurus)
    CL Item
    Stable Disease (SD)
    C18213 (NCI Thesaurus)
    C0677946 (UMLS 2011AA)
    CL Item
    Progressive Disease (PD)
    C35571 (NCI Thesaurus)
    C1335499 (UMLS 2011AA)
    Item
    Was the appearance of any new lesions documented (If PD: check one NOTE: If PD is selected for Overall Response Status, and Yes is selected for "Was the appearance of any new lesions documented" end form)
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C3824 (NCI Thesaurus ObjectClass)
    C0221198 (UMLS 2011AA ObjectClass)
    C25586 (NCI Thesaurus ObjectClass)
    C0205314 (UMLS 2011AA ObjectClass)
    C25377 (NCI Thesaurus Property)
    C0700364 (UMLS 2011AA Property)
    CL.4
    Code List
    Was the appearance of any new lesions documented (If PD: check one NOTE: If PD is selected for Overall Response Status, and Yes is selected for "Was the appearance of any new lesions documented" end form)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Overall Response Status
    AssessmentPerformedDate
    Item
    Assessment date (dd MMM yyyy Assessment date is the date reflecting type of assessment, not the physician interpretation date. If tumor measurements are not required this cycle per Section 4.0, Assessment Date is the date the patient was evaluated )
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    NonNodalTargetLesionPresentSite
    Item
    Non-nodal target lesion site(s) (Primary Tumor)
    text
    C3824 (NCI Thesaurus ObjectClass)
    C0221198 (UMLS 2011AA ObjectClass)
    C25594 (NCI Thesaurus ObjectClass)
    C1518422 (UMLS 2011AA ObjectClass)
    C25323 (NCI Thesaurus ObjectClass)
    C0443268 (UMLS 2011AA ObjectClass)
    C25702 (NCI Thesaurus ObjectClass)
    C1521840 (UMLS 2011AA ObjectClass)
    C25626 (NCI Thesaurus Property)
    C0150312 (UMLS 2011AA Property)
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    Item
    Method of Evaluation
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus ObjectClass)
    C0031809 (UMLS 2011AA ObjectClass)
    C16847 (NCI Thesaurus Property)
    C0449851 (UMLS 2011AA Property)
    CL.5
    Code List
    Method of Evaluation
    CL Item
    Ct Scan (CT scan)
    CL Item
    Pet/ct Scan (PET/CT scan)
    NegationNodalTargetLesionLongestDiameterMeasurement
    Item
    Non-Nodal Longest Diameter of Lesion(s) (Primary Tumor cm)
    double
    C3824 (NCI Thesaurus ObjectClass)
    C0221198 (UMLS 2011AA ObjectClass)
    C25594 (NCI Thesaurus ObjectClass)
    C1518422 (UMLS 2011AA ObjectClass)
    C25323 (NCI Thesaurus ObjectClass)
    C0443268 (UMLS 2011AA ObjectClass)
    C25702 (NCI Thesaurus ObjectClass)
    C1521840 (UMLS 2011AA ObjectClass)
    C25285 (NCI Thesaurus Property)
    C1301886 (UMLS 2011AA Property)
    C25558 (NCI Thesaurus Property)
    C1522425 (UMLS 2011AA Property)
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C25285 (NCI Thesaurus ValueDomain)
    C1301886 (UMLS 2011AA ValueDomain)
    Tillbaka till toppen 

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