ID

2456

Beschrijving

S0201 Observation Arm Assessment Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93268F8-DF07-6139-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93268F8-DF07-6139-E034-0003BA12F5E7

Trefwoorden

  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

19 september 2012

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy

Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Melanoma (Skin) null Toxicity - S0201 Observation Arm Assessment Form - 2055704v3.0

Instructions: Complete at the end of weeks 12, 27, 54, 81. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in a Comments section. Place an X in appropriate boxes. Circle AMENDED items

Unnamed1
Beschrijving

Unnamed1

SWOG Patient ID
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
Reporting interval number
Beschrijving

Reportingintervalnumber

Datatype

text

If reporting interval #1, then Indicate week number for this submission
Beschrijving

Ifreportinginterval#1,thenIndicateweeknumberforthissubmission

Datatype

text

Institution/Affiliate
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Physician
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. ID
Beschrijving

Pt.ID

Datatype

text

Disease Status
Beschrijving

Disease Status

Date of Last Contact or Death
Beschrijving

DeathDate/LastContactDate

Datatype

date

Vital Status
Beschrijving

Patient'sVitalStatus

Datatype

text

Reporting interval start date
Beschrijving

IntervalReportFromDate

Datatype

date

Reporting interval end date
Beschrijving

IntervalReportToDate

Datatype

date

Adverse Events
Beschrijving

Adverse Events

Were adverse events assessed during this time period?
Beschrijving

Weretoxicitiesassessedforthisreportinginterval?

Datatype

text

Date of most recent toxicity assessment
Beschrijving

SymptomAssessmentDate

Datatype

date

Unnamed3
Beschrijving

Unnamed3

Datatype

text

Code
Beschrijving

CTCCode

Datatype

text

Adverse Event
Beschrijving

CTCAdverseEventTerm

Datatype

text

CTC 2.0 Grade (0-5)
Beschrijving

CTCAdverseEventGrade

Datatype

text

Other Toxicities (specify)
Beschrijving

CTCAdverseEventTerm,Other

Datatype

text

Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

Ccrr Module For S0201 Observation Arm Assessment Form
Beschrijving

Ccrr Module For S0201 Observation Arm Assessment Form

Similar models

Instructions: Complete at the end of weeks 12, 27, 54, 81. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in a Comments section. Place an X in appropriate boxes. Circle AMENDED items

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
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)
Reportingintervalnumber
Item
Reporting interval number
text
Item
If reporting interval #1, then Indicate week number for this submission
text
Code List
If reporting interval #1, then Indicate week number for this submission
CL Item
Week 12 (Week 12)
CL Item
Week 27 (week 27)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician
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. ID
text
Item Group
Disease Status
DeathDate/LastContactDate
Item
Date of Last Contact or Death
date
Item
Vital Status
text
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
IntervalReportFromDate
Item
Reporting interval start date
date
IntervalReportToDate
Item
Reporting interval end date
date
Item Group
Adverse Events
Item
Were adverse events assessed during this time period?
text
Code List
Were adverse events assessed during this time period?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SymptomAssessmentDate
Item
Date of most recent toxicity assessment
date
Item
Unnamed3
text
Code List
Unnamed3
CL Item
Mark Box If Toxicities Were Assessed But None Were Seen. (Mark box if toxicities were assessed but none were seen.)
CTCCode
Item
Code
text
CTCAdverseEventTerm
Item
Adverse Event
text
Item
CTC 2.0 Grade (0-5)
text
Code List
CTC 2.0 Grade (0-5)
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CTCAdverseEventTerm,Other
Item
Other Toxicities (specify)
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0201 Observation Arm Assessment Form

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial