ID

25154

Description

AMC-053 Off-Study Summary Form (F50) Bortezomib, Ifosfamide, Carboplatin, and Etoposide, With or Without Rituximab, in Treating Patients With Relapsed or Refractory AIDS-Related Non-Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8B708D70-669B-F9DE-E040-BB89AD43114E

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8B708D70-669B-F9DE-E040-BB89AD43114E

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/28/17 8/28/17 -
Uploaded on

August 28, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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AMC-053 Off-Study Summary Form (F50)

English

Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)

1 forms  
Ccrr Module For Off Study Summary - Rf50
Description

Ccrr Module For Off Study Summary - Rf50

Alias
UMLS CUI-1
C1518546
UMLS CUI-2
C1706244
UMLS CUI-3
C1332051
Off Study Date
Description

Off-TreatmentStudyFollow-UpEndDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
NCI Thesaurus Property
C25275
UMLS CUI [1,1]
C1518544
UMLS CUI [1,2]
C0011008
Off Study Reason
Description

Off-TreatmentStudyFollow-UpReason (select the primary reason)

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C1518546
UMLS CUI [1,3]
C0392360
Other, specify
Description

Off-TreatmentStudyFollow-UpSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass-2
C15206
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C1518546
UMLS CUI [1,3]
C0392360
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1332051
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Similar models

Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Off Study Summary - Rf50
C1518546 (UMLS CUI-1)
C1706244 (UMLS CUI-2)
C1332051 (UMLS CUI-3)
Off Study Date
Item
Off Study Date
date
C25164 (NCI Thesaurus ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C25275 (NCI Thesaurus Property)
C1518544 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Off Study Reason
integer
C25638 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
CL.1
Code List
Off Study Reason
CL Item
Protocol-defined Follow-up Completed (1)
CL Item
Lost To Follow-up (2)
CL Item
Patient Refused Follow-up (3)
CL Item
Death (4)
CL Item
Adverse Event/side Effects/complications (5)
CL Item
Other (6)
Other, specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C1522577 (UMLS CUI [1,1])
C1518546 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1,1])
C1332051 (UMLS CUI [1,2])
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