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2519

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Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form Carboplatin and Paclitaxel With or Without Bevacizumab and/or Cetuximab in Treating Patients With Stage IV or Recurrent Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=684FE956-5A8B-A7DA-E040-BB89AD432A2B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=684FE956-5A8B-A7DA-E040-BB89AD432A2B

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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September 19, 2012

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Creative Commons BY-NC 3.0 Legacy
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    Lung Cancer NCT00946712 On-Study - Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form - 2863883v1.0

    English

    Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red

    1 forms  
    1. StudyEvent: Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form
      1. Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red
    Unnamed1
    Description

    Unnamed1

    SWOG Patient ID
    Description

    PatientSouthwestOncologyGroupIdentifierNumber

    Data type

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25699
    UMLS 2011AA Property
    C1519429
    SWOG Study No.
    Description

    ProtocolSWOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25699
    UMLS 2011AA Property
    C1519429
    Registration Step
    Description

    RegistrationStepNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C16154
    UMLS 2011AA Property
    C1704379
    NCI Thesaurus ValueDomain
    C16154
    UMLS 2011AA ValueDomain
    C1704379
    Patient Initials (L, F M)
    Description

    PatientInitialsName

    Data type

    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/Affiliate
    Description

    CombinedInstitutionName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS 2011AA ObjectClass
    C0205195
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    Physician
    Description

    RegisteredInvestigatorName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    NCI Thesaurus ObjectClass
    C25644
    Participating Group Name
    Description

    ParticipatingGroupName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25608
    UMLS 2011AA ObjectClass
    C0679823
    NCI Thesaurus ObjectClass
    C17005
    UMLS 2011AA ObjectClass
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Study No.
    Description

    ProtocolParticipatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Patient ID
    Description

    PatientParticipatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Vital Status
    Description

    Vital Status

    Date of Last Contact or Death (MM DD YYYY)
    Description

    PatientLastContactDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25461
    UMLS 2011AA Property
    C0337611
    NCI Thesaurus Property
    C25551
    UMLS 2011AA Property
    C1517741
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    Vital Status
    Description

    PatientVitalStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain
    C18003
    UMLS 2011AA ValueDomain
    C0442732
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    NCI Thesaurus Property
    C25717
    UMLS 2011AA Property
    C1148433
    Progression Or Relapse
    Description

    Progression Or Relapse

    Date of Relapse or Progression (MM DD YYYY)
    Description

    DiseaseRecurrentDiseaseCancerProgressionDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C38155
    UMLS 2011AA Property
    C0277556
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus Property
    C19987
    UMLS 2011AA Property
    C0242656
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Sites of Progression (or Relapse at the time progression/relapse was detected select all that apply)
    Description

    ProgressionSite

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus ObjectClass
    C25331
    Other specify (site)
    Description

    FirstProgressionLocal-RegionalSiteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25331
    NCI Thesaurus ObjectClass
    C25509
    UMLS 2011AA ObjectClass
    C1279901
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property
    C25388
    UMLS 2011AA Property
    C1947913
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    Description

    RadiationFieldCancerProgressionIndicator

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C54648
    UMLS 2011AA ObjectClass
    C1882536
    NCI Thesaurus Property
    C19987
    UMLS 2011AA Property
    C0242656
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    Description

    RadiationFieldCancerProgressionIndicator

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C54648
    UMLS 2011AA ObjectClass
    C1882536
    NCI Thesaurus Property
    C19987
    UMLS 2011AA Property
    C0242656
    Comments
    Description

    Comments

    Comments
    Description

    ResearchCommentsText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
    Back to the top of the page

    Similar models

    Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red

    1 forms
    1. StudyEvent: Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form
      1. Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Unnamed1
    PatientSouthwestOncologyGroupIdentifierNumber
    Item
    SWOG Patient ID
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property)
    C1519429 (UMLS 2011AA Property)
    ProtocolSWOGIdentifierNumber
    Item
    SWOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property)
    C1519429 (UMLS 2011AA Property)
    RegistrationStepNumber
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C16154 (NCI Thesaurus Property)
    C1704379 (UMLS 2011AA Property)
    C16154 (NCI Thesaurus ValueDomain)
    C1704379 (UMLS 2011AA ValueDomain)
    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)
    CombinedInstitutionName
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C0205195 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    RegisteredInvestigatorName
    Item
    Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
    C25644 (NCI Thesaurus ObjectClass)
    ParticipatingGroupName
    Item
    Participating Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25608 (NCI Thesaurus ObjectClass)
    C0679823 (UMLS 2011AA ObjectClass)
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolParticipatingIdentifierNumber
    Item
    Participating Group Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientParticipatingIdentifierNumber
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Item Group
    Vital Status
    PatientLastContactDate
    Item
    Date of Last Contact or Death (MM DD YYYY)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25461 (NCI Thesaurus Property)
    C0337611 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus Property)
    C1517741 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    Item
    Vital Status
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C18003 (NCI Thesaurus ValueDomain)
    C0442732 (UMLS 2011AA ValueDomain)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    C25717 (NCI Thesaurus Property)
    C1148433 (UMLS 2011AA Property)
    CL.1
    Code List
    Vital Status
    CL Item
    Alive (Alive)
    CL Item
    Dead (Dead)
    Item Group
    Progression Or Relapse
    DiseaseRecurrentDiseaseCancerProgressionDiagnosisDate
    Item
    Date of Relapse or Progression (MM DD YYYY)
    date
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C38155 (NCI Thesaurus Property)
    C0277556 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C19987 (NCI Thesaurus Property)
    C0242656 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Sites of Progression (or Relapse at the time progression/relapse was detected select all that apply)
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25331 (NCI Thesaurus ObjectClass)
    CL.2
    Code List
    Sites of Progression (or Relapse at the time progression/relapse was detected select all that apply)
    CL Item
    Lung Parenchyma Adjacent To Primary Tumor (Lung parenchyma adjacent to primary tumor)
    CL Item
    Bronchial Stump (Bronchial stump)
    CL Item
    Ipsilateral Hilar Mediastinum (nodal) (Ipsilateral hilar mediastinum (nodal))
    CL Item
    Contralateral Hilar Mediastinum (nodal) (Contralateral hilar mediastinum (nodal))
    CL Item
    Ipsilateral Pleural Effusion (Ipsilateral pleural effusion)
    CL Item
    Contralateral Pleural Effusion (Contralateral pleural effusion)
    CL Item
    Ipsilateral Supraclavicular Nodes (Ipsilateral supraclavicular nodes)
    CL Item
    Contralateral Supraclavicular Nodes (Contralateral supraclavicular nodes)
    CL Item
    Separate Lobe Of The Ipsilateral Lung (Separate lobe of the ipsilateral lung)
    CL Item
    Contralateral Lung (Opposite lung)
    CL Item
    Pericardial Effusion (Pericardial effusion)
    C3319 (NCI Thesaurus)
    C0031039 (UMLS 2011AA)
    CL Item
    Brain (Brain)
    C12439 (NCI Thesaurus)
    C0006104 (UMLS 2011AA)
    CL Item
    Leptomeninges (Leptomeninges)
    C32979 (NCI Thesaurus)
    C0228126 (UMLS 2011AA)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Bone (Bone)
    C12366 (NCI Thesaurus)
    C0262950 (UMLS 2011AA)
    CL Item
    Adrenal Gland (Adrenal glands)
    C12666 (NCI Thesaurus)
    C0001625 (UMLS 2011AA)
    CL Item
    Kidney (Kidney)
    C12415 (NCI Thesaurus)
    C0022646 (UMLS 2011AA)
    CL Item
    Subcutaneous/skin (Subcutaneous/Skin)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    FirstProgressionLocal-RegionalSiteSpecify
    Item
    Other specify (site)
    text
    C25331 (NCI Thesaurus ObjectClass)
    C25509 (NCI Thesaurus ObjectClass)
    C1279901 (UMLS 2011AA ObjectClass)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25388 (NCI Thesaurus Property)
    C1947913 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C54648 (NCI Thesaurus ObjectClass)
    C1882536 (UMLS 2011AA ObjectClass)
    C19987 (NCI Thesaurus Property)
    C0242656 (UMLS 2011AA Property)
    CL.4
    Code List
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Not Applicable (Not Applicable)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C54648 (NCI Thesaurus ObjectClass)
    C1882536 (UMLS 2011AA ObjectClass)
    C19987 (NCI Thesaurus Property)
    C0242656 (UMLS 2011AA Property)
    CL.4
    Code List
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Not Applicable (Not Applicable)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
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