ID

2571

Descrição

CALGB 50901 Confirmation of Lost to Follow-Up Form Ofatumumab in Treating Patients With Previously Untreated Stage II, Stage III, or Stage IV Follicular Non-Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9F9012C3-FDE7-DB91-E040-BB89AD432434

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9F9012C3-FDE7-DB91-E040-BB89AD432434

Palavras-chave

Versões (2)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

19 de setembro de 2012

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy
Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo
Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

Lymphoma NCT01190449 Follow-Up - CALGB 50901 Confirmation of Lost to Follow-Up Form - 3211940v1.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: CALGB 50901 Confirmation of Lost to Follow-Up Form
    1. No Instruction available.
Criteria For Lost To Follow-up Status
Descrição

Criteria For Lost To Follow-up Status

Has it been at least 2 years since you were last able to contact the patient
Descrição

PatientLostFollow-upInd-2

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25560
UMLS 2011AA Property
C0745777
NCI Thesaurus Property
C16033
UMLS 2011AA Property
C1522577
Date of Last Contact (prior to this confirmation)
Descrição

LastContactDate

Tipo de dados

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C47954
UMLS 2011AA ObjectClass
C1705415
NCI Thesaurus ObjectClass
C25551
UMLS 2011AA ObjectClass
C1517741
Contact Type (Please indicate when steps were taken to contact the patient. Both Social Security Death Index and Certified/Registered Letter methods must be attempted without success after 2 years without contact before a patient can be declared lost)
Descrição

PatientContactTextType

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25461
UMLS 2011AA Property
C0337611
Contact Type (Please indicate when steps were taken to contact the patient. Both Social Security Death Index and Certified/Registered Letter methods must be attempted without success after 2 years without contact before a patient can be declared lost)
Descrição

PatientContactTextType

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25461
UMLS 2011AA Property
C0337611
Specify most recent date
Descrição

PatientLastAttemptContactDate

Tipo de dados

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 Property
C39769
UMLS 2011AA Property
C1516084
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Specify most recent date
Descrição

PatientLastAttemptContactDate

Tipo de dados

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 Property
C39769
UMLS 2011AA Property
C1516084
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Patient Contact Status
Descrição

PatientAttemptContactStatus

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25461
UMLS 2011AA Property
C0337611
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C39769
UMLS 2011AA Property
C1516084
Investigator Signature (Required for patients who have been lost for 2 years: I verify that the above information is correct and that all attempts to contact this patient have failed)
Descrição

InvestigatorSignatureText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Descrição

InvestigatorSignatureDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Patient No Longer Lost To Follow-up
Descrição

Patient No Longer Lost To Follow-up

New information for this patient is now available for
Descrição

PatientViableFollow-UpStatus

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C16033
UMLS 2011AA Property
C1522577
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25324
UMLS 2011AA Property
C0443348
Vital Status (based on new data)
Descrição

PatientVitalStatus

Tipo de dados

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
Date of Last Contact or Death
Descrição

PatientLastContactDate

Tipo de dados

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
Voltar ao início da página

Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: CALGB 50901 Confirmation of Lost to Follow-Up Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Criteria For Lost To Follow-up Status
Item
Has it been at least 2 years since you were last able to contact the patient
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25560 (NCI Thesaurus Property)
C0745777 (UMLS 2011AA Property)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
CL.1
Code List
Has it been at least 2 years since you were last able to contact the patient
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
LastContactDate
Item
Date of Last Contact (prior to this confirmation)
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C47954 (NCI Thesaurus ObjectClass)
C1705415 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass)
C1517741 (UMLS 2011AA ObjectClass)
Item
Contact Type (Please indicate when steps were taken to contact the patient. Both Social Security Death Index and Certified/Registered Letter methods must be attempted without success after 2 years without contact before a patient can be declared lost)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25461 (NCI Thesaurus Property)
C0337611 (UMLS 2011AA Property)
CL.3
Code List
Contact Type (Please indicate when steps were taken to contact the patient. Both Social Security Death Index and Certified/Registered Letter methods must be attempted without success after 2 years without contact before a patient can be declared lost)
CL Item
Mail Contact With Patient/participant (Mail contact with Patient/Participant)
Item
Contact Type (Please indicate when steps were taken to contact the patient. Both Social Security Death Index and Certified/Registered Letter methods must be attempted without success after 2 years without contact before a patient can be declared lost)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25461 (NCI Thesaurus Property)
C0337611 (UMLS 2011AA Property)
CL.3
Code List
Contact Type (Please indicate when steps were taken to contact the patient. Both Social Security Death Index and Certified/Registered Letter methods must be attempted without success after 2 years without contact before a patient can be declared lost)
CL Item
Mail Contact With Patient/participant (Mail contact with Patient/Participant)
PatientLastAttemptContactDate
Item
Specify most recent date
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)
C39769 (NCI Thesaurus Property)
C1516084 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PatientLastAttemptContactDate
Item
Specify most recent date
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)
C39769 (NCI Thesaurus Property)
C1516084 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Patient Contact Status
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25461 (NCI Thesaurus Property)
C0337611 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C39769 (NCI Thesaurus Property)
C1516084 (UMLS 2011AA Property)
CL.4
Code List
Patient Contact Status
CL Item
Letter Returned Unclaimed Or Marked Addressee Unknown (Letter returned unclaimed or marked addressee unknown)
CL Item
No Response 1 Month After Confirmed Receipt Of Letter (No response 1 month after confirmed receipt of letter)
InvestigatorSignatureText
Item
Investigator Signature (Required for patients who have been lost for 2 years: I verify that the above information is correct and that all attempts to contact this patient have failed)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
Item Group
Patient No Longer Lost To Follow-up
Item
New information for this patient is now available for
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25324 (NCI Thesaurus Property)
C0443348 (UMLS 2011AA Property)
CL.5
Code List
New information for this patient is now available for
CL Item
Survival Status Only (Survival status only)
CL Item
Clinical And Survival Status (Clinical and survival status)
Item
Vital Status (based on new data)
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.6
Code List
Vital Status (based on new data)
CL Item
Alive (Alive)
CL Item
Dead (Dead)
PatientLastContactDate
Item
Date of Last Contact or Death
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)
Voltar ao início da página 

Contacto

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

Ajuda

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