ID

2336

Beschrijving

Termination of Patient Follow-up (TPFU) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B1243BAC-D9BC-4E9B-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B1243BAC-D9BC-4E9B-E034-0003BA12F5E7

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
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 - Termination of Patient Follow-up (TPFU) - 2074808v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Termination of Patient Follow-up (TPFU)
    1. No Instruction available.
Ccrr Module For Termination Of Patient Follow-up (tpfu)
Beschrijving

Ccrr Module For Termination Of Patient Follow-up (tpfu)

Patient ID (Pt. ID issued during registration or previously issued patient ID)
Beschrijving

Pt.ID

Datatype

text

Institution ID:
Beschrijving

InstitutionNo.

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Initials: (F ML)
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:
Beschrijving

InstitutionName

Datatype

text

Date of Study Completion or Early Follow-up Terminiation (Year Month Day)
Beschrijving

PatientEndFollow-upDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C16033
UMLS 2011AA Property
C1522577
NCI Thesaurus Property
C25496
UMLS 2011AA Property
C2746065
Did the Patient complete the study per protocol
Beschrijving

Follow-UpPatientCompleteStudyInd-2

Datatype

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C16033
UMLS 2011AA Property
C1522577
NCI Thesaurus Property
C25496
UMLS 2011AA Property
C2746065
Reason for early termination of patient follow-up (mark x only one:)
Beschrijving

Off-TreatmentACOSOGReason

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C19712
UMLS 2011AA Property
C1515944
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Adverse event, (specify)
Beschrijving

Adverseevent,

Datatype

text

Patient declared ineligible (specify)
Beschrijving

Patientdeclaredineligible

Datatype

text

Other, (specify)
Beschrijving

Other,

Datatype

text

Early follow-up termination authorization number:
Beschrijving

Off-TreatmentACOSOGDescriptionNumber

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C19712
UMLS 2011AA Property
C1515944
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Completed by:
Beschrijving

CompletedBy

Datatype

text

Date:
Beschrijving

FormCompletionDate,Original

Datatype

date

Year Month Day
Beschrijving

YearMonthDay

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Termination of Patient Follow-up (TPFU)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Ccrr Module For Termination Of Patient Follow-up (tpfu)
Pt.ID
Item
Patient ID (Pt. ID issued during registration or previously issued patient ID)
text
InstitutionNo.
Item
Institution ID:
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientInitialsName
Item
Patient Initials: (F ML)
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)
InstitutionName
Item
Institution:
text
PatientEndFollow-upDate
Item
Date of Study Completion or Early Follow-up Terminiation (Year Month Day)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
Item
Did the Patient complete the study per protocol
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
CL.1
Code List
Did the Patient complete the study per protocol
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Reason for early termination of patient follow-up (mark x only one:)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C19712 (NCI Thesaurus Property)
C1515944 (UMLS 2011AA Property)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.2
Code List
Reason for early termination of patient follow-up (mark x only one:)
CL Item
Adverse Event (Adverse event, specify)
C41331 (NCI Thesaurus)
C0877248 (UMLS 2011AA)
CL Item
Patient Follow-up Terminated For Other Complicating Disease. (Patient follow-up terminated for other complicating disease.)
CL Item
Patient Withdrew Consent. (Patient withdrew consent.)
CL Item
Patient Declared Ineligible (Patient declared ineligible, specify)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Adverseevent,
Item
Adverse event, (specify)
text
Patientdeclaredineligible
Item
Patient declared ineligible (specify)
text
Other,
Item
Other, (specify)
text
Off-TreatmentACOSOGDescriptionNumber
Item
Early follow-up termination authorization number:
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19712 (NCI Thesaurus Property)
C1515944 (UMLS 2011AA Property)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CompletedBy
Item
Completed by:
text
FormCompletionDate,Original
Item
Date:
date
YearMonthDay
Item
Year Month Day
text
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