ID

2331

Beschreibung

Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA0178-CF14-0F96-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA0178-CF14-0F96-E034-0003BA12F5E7

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 03.07.15 03.07.15 -
Hochgeladen am

19. September 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Melanoma (Skin) null Follow-Up - Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up - 2038060v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
    1. No Instruction available.
Unnamed 1
Beschreibung

Unnamed 1

SWOG Patient No
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient Initials (L, F M)
Beschreibung

PatientInitialsName

Datentyp

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/Member
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Physician (Groups other than SWOG)
Beschreibung

TreatingPhysician

Datentyp

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Group Name
Beschreibung

ParticipatingGroupName

Datentyp

text

Study No.
Beschreibung

StudyNo.

Datentyp

text

Pt. No
Beschreibung

Pt.ID

Datentyp

text

Vital Status
Beschreibung

Vital Status

Vital Status
Beschreibung

Patient'sVitalStatus

Datentyp

text

Date of last contact or death
Beschreibung

DeathDate/LastContactDate

Datentyp

date

Disease Follow-up Status
Beschreibung

Disease Follow-up Status

Has the patient been assessed for this cancer since submission of the last form?
Beschreibung

CancerFollow-upStatusInd

Datentyp

text

Date of assessment
Beschreibung

CancerFollow-upStatusDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of First Relapse Or Progression
Beschreibung

Notice Of First Relapse Or Progression

Has the patient had a first relapse or progression of this cancer that has not been previously reported?
Beschreibung

ProgressionInd

Datentyp

text

Date of Relapse
Beschreibung

ProgressionDate

Datentyp

date

Site(s) of relapse
Beschreibung

Sites(progressionorrelapse)

Datentyp

text

Notice Of New Primary
Beschreibung

Notice Of New Primary

Has a new malignant neoplasm or myelodysplastic syndrome (MDS) been diagnosed since the last form?
Beschreibung

Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date of new primary
Beschreibung

NewPrimaryCancerDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Specify new primary site
Beschreibung

NewPrimarySite

Datentyp

text

Non-protocol Treatment
Beschreibung

Non-protocol Treatment

Has the patient received any (non-protocol) cancer treatment since submission of the last S0201 Adjuvant Melanoma Follow-up Form?
Beschreibung

Non-ProtocolTherapyInd

Datentyp

text

Surgery?
Beschreibung

Non-protocolSurgeryPerformedInd-3

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
Date (surgery)
Beschreibung

SurgeryDate

Datentyp

date

Specify (surgery
Beschreibung

Non-ProtocolSurgeryType

Datentyp

text

Systemic therapy?
Beschreibung

Non-ProtocolChemotherapyInd

Datentyp

text

Date (systemic therapy)
Beschreibung

ChemotherapyBeginDate

Datentyp

date

Specify agents, dose, schedule
Beschreibung

Non-ProtocolChemotherapyAdministeredSpecify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Radiation Therapy?
Beschreibung

Non-ProtocolRTInd

Datentyp

text

Date (RT)
Beschreibung

RTBeginDate

Datentyp

date

Specify (RT)
Beschreibung

Non-ProtocolRTType

Datentyp

text

Other therapy?
Beschreibung

OtherTherapyInd

Datentyp

text

Specify (other therapy)
Beschreibung

OtherTherapyName

Datentyp

text

Ccrr Module For Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
Beschreibung

Ccrr Module For Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up

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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed 1
SWOGPatientID
Item
SWOG Patient No
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
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)
MainMemberInstitution/Affiliate
Item
Institution/Member
text
TreatingPhysician
Item
Physician (Groups other than SWOG)
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
ParticipatingGroupName
Item
Group Name
text
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. No
text
Item Group
Vital Status
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death
date
Item Group
Disease Follow-up Status
Item
Has the patient been assessed for this cancer since submission of the last form?
text
CL.2
Code List
Has the patient been assessed for this cancer since submission of the last form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of assessment
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Notice Of First Relapse Or Progression
Item
Has the patient had a first relapse or progression of this cancer that has not been previously reported?
text
CL.3
Code List
Has the patient had a first relapse or progression of this cancer that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate
Item
Date of Relapse
date
Item
Site(s) of relapse
text
CL.4
Code List
Site(s) of relapse
CL Item
Local Recurrence (local-recurrence)
CL Item
In-transit Recurrence (in-transit recurrence)
CL Item
Regional Recurrence (regional recurrence)
CL Item
Distant Metastasis (distant metastasis)
C18206 (NCI Thesaurus)
C1269798 (UMLS 2011AA)
Item Group
Notice Of New Primary
Item
Has a new malignant neoplasm or myelodysplastic syndrome (MDS) been diagnosed since the last form?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.5
Code List
Has a new malignant neoplasm or myelodysplastic syndrome (MDS) been diagnosed since the last form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimaryCancerDate
Item
Date of new primary
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
Specify new primary site
text
Item Group
Non-protocol Treatment
Item
Has the patient received any (non-protocol) cancer treatment since submission of the last S0201 Adjuvant Melanoma Follow-up Form?
text
CL.6
Code List
Has the patient received any (non-protocol) cancer treatment since submission of the last S0201 Adjuvant Melanoma Follow-up Form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Surgery?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
CL.7
Code List
Surgery?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SurgeryDate
Item
Date (surgery)
date
Non-ProtocolSurgeryType
Item
Specify (surgery
text
Item
Systemic therapy?
text
CL.8
Code List
Systemic therapy?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ChemotherapyBeginDate
Item
Date (systemic therapy)
date
Non-ProtocolChemotherapyAdministeredSpecify
Item
Specify agents, dose, schedule
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Radiation Therapy?
text
CL.9
Code List
Radiation Therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
RTBeginDate
Item
Date (RT)
date
Non-ProtocolRTType
Item
Specify (RT)
text
Item
Other therapy?
text
CL.10
Code List
Other therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
OtherTherapyName
Item
Specify (other therapy)
text
Item Group
Ccrr Module For Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
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