ID

2331

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 03-07-15 03-07-15 -
Geüploaded op

19 september 2012

DOI

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Licentie

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

Engels

No Instruction available.

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

Unnamed 1

SWOG Patient No
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F M)
Beschrijving

PatientInitialsName

Datatype

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
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Physician (Groups other than SWOG)
Beschrijving

TreatingPhysician

Datatype

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
Beschrijving

ParticipatingGroupName

Datatype

text

Study No.
Beschrijving

StudyNo.

Datatype

text

Pt. No
Beschrijving

Pt.ID

Datatype

text

Vital Status
Beschrijving

Vital Status

Vital Status
Beschrijving

Patient'sVitalStatus

Datatype

text

Date of last contact or death
Beschrijving

DeathDate/LastContactDate

Datatype

date

Disease Follow-up Status
Beschrijving

Disease Follow-up Status

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

CancerFollow-upStatusInd

Datatype

text

Date of assessment
Beschrijving

CancerFollow-upStatusDate

Datatype

date

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

Notice Of First Relapse Or Progression

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

ProgressionInd

Datatype

text

Date of Relapse
Beschrijving

ProgressionDate

Datatype

date

Site(s) of relapse
Beschrijving

Sites(progressionorrelapse)

Datatype

text

Notice Of New Primary
Beschrijving

Notice Of New Primary

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

Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?

Datatype

text

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

NewPrimaryCancerDate

Datatype

date

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

NewPrimarySite

Datatype

text

Non-protocol Treatment
Beschrijving

Non-protocol Treatment

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

Non-ProtocolTherapyInd

Datatype

text

Surgery?
Beschrijving

Non-protocolSurgeryPerformedInd-3

Datatype

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)
Beschrijving

SurgeryDate

Datatype

date

Specify (surgery
Beschrijving

Non-ProtocolSurgeryType

Datatype

text

Systemic therapy?
Beschrijving

Non-ProtocolChemotherapyInd

Datatype

text

Date (systemic therapy)
Beschrijving

ChemotherapyBeginDate

Datatype

date

Specify agents, dose, schedule
Beschrijving

Non-ProtocolChemotherapyAdministeredSpecify

Datatype

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?
Beschrijving

Non-ProtocolRTInd

Datatype

text

Date (RT)
Beschrijving

RTBeginDate

Datatype

date

Specify (RT)
Beschrijving

Non-ProtocolRTType

Datatype

text

Other therapy?
Beschrijving

OtherTherapyInd

Datatype

text

Specify (other therapy)
Beschrijving

OtherTherapyName

Datatype

text

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

Ccrr Module For Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Southwest Oncology Group S0201 Adjuvant Melanoma Follow Up
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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