ID

2759

Beschreibung

Non-Protocol Therapy Form Gemcitabine With or Without Radiation Therapy in Treating Patients With Pancreatic Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6247E9A-A888-3C19-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6247E9A-A888-3C19-E034-0003BA0B1A09

Stichworte

  1. 19.09.12 19.09.12 -
  2. 28.05.15 28.05.15 -
  3. 03.06.15 03.06.15 -
Hochgeladen am

19. September 2012

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy

Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Pancreatic Cancer NCT00057876 Treatment - Non-Protocol Therapy Form - 2047033v3.0

No Instruction available.

  1. StudyEvent: Non-Protocol Therapy Form
    1. No Instruction available.
Unnamed1
Beschreibung

Unnamed1

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient?s Name
Beschreibung

Patient'sName

Datentyp

text

ECOG Protocol No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Protocol No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Patient ID
Beschreibung

ECOGPatientID

Datentyp

text

ECOG Patient ID
Beschreibung

ECOGPatientID

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Participating Group Patient ID
Beschreibung

ParticipatingGroupPatientID

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Unnamed2
Beschreibung

Unnamed2

Are data amended? (If yes, please circle amended items in red)
Beschreibung

AmendedDataInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed3
Beschreibung

Unnamed3

Date of FIRST non-protocol therapy (if given prior to progression/relapse from protocol therapy:)
Beschreibung

Non-ProtocolTherapyDate,First

Datentyp

date

Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen.)
Beschreibung

Type(s)offirstnon-protocoltherapy

Datentyp

text

Name of other non-protocol therapy:
Beschreibung

OtherNon-ProtocolTherapyName

Datentyp

text

Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
Beschreibung

Wasthenon-protocoltherapygivenforthediseaseofthisprotocol?

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beschreibung

InvestigatorSignatureDate

Datentyp

date

Ccrr Module For Non-protocol Therapy Form
Beschreibung

Ccrr Module For Non-protocol Therapy Form

Non-protocol chemotherapy
Beschreibung

Non-ProtocolChemotherapyInd

Datentyp

text

Non-protocol hormonal therapy
Beschreibung

Non-ProtocolHormonalTherapyInd

Datentyp

text

Non-protocol immunotherapy/biologic response modifiers
Beschreibung

Non-ProtocolImmunotherapyInd

Datentyp

text

Other non-protocol therapy
Beschreibung

OtherTherapyInd

Datentyp

text

Non-protocol surgery
Beschreibung

Non-protocolSurgeryPerformedInd-3

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
Non-protocol radiation therapy
Beschreibung

Non-ProtocolRTInd

Datentyp

text

Non-protocol high dose chemotherapy/stem cell transplant
Beschreibung

Non-ProtocolHDC/ASCTInd

Datentyp

text

Ähnliche Modelle

No Instruction available.

  1. StudyEvent: Non-Protocol Therapy Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Unnamed2
Item
Are data amended? (If yes, please circle amended items in red)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed3
Non-ProtocolTherapyDate,First
Item
Date of FIRST non-protocol therapy (if given prior to progression/relapse from protocol therapy:)
date
Item
Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen.)
text
Code List
Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen.)
CL Item
Non-protocol Chemotherapy (Non-protocol Chemotherapy)
CL Item
Non-protocol Hormonal Therapy (Non-protocol Hormonal Therapy)
CL Item
Non-protocol Immunotherapy/biological Response Modifiers (Non-protocol Immunotherapy/Biological Response Modifiers)
CL Item
Non-protocol High Dose Chemotherapy/stem Cell Transplant (autologous Or Allogeneic) (Non-protocol High Dose Chemotherapy/Stem Cell Transplant (Autologous or Allogeneic))
CL Item
Non-protocol Surgery (Non-protocol Surgery)
CL Item
Non-protocol Radiation Therapy (Non-protocol Radiation Therapy)
CL Item
Other Non-protocol Therapy (Other Non-protocol Therapy)
OtherNon-ProtocolTherapyName
Item
Name of other non-protocol therapy:
text
Item
Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Comments
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Non-protocol Therapy Form
Item
Non-protocol chemotherapy
text
Code List
Non-protocol chemotherapy
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Non-protocol hormonal therapy
text
Code List
Non-protocol hormonal therapy
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Non-protocol immunotherapy/biologic response modifiers
text
Code List
Non-protocol immunotherapy/biologic response modifiers
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Other non-protocol therapy
text
Code List
Other non-protocol therapy
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Non-protocol surgery
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
Code List
Non-protocol surgery
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Non-protocol radiation therapy
text
Code List
Non-protocol radiation therapy
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Non-protocol high dose chemotherapy/stem cell transplant
text
Code List
Non-protocol high dose chemotherapy/stem cell transplant
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video