ID

2759

Descrizione

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

collegamento

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

Keywords

versioni (3)
  1. 19/09/12 19/09/12 -
  2. 28/05/15 28/05/15 -
  3. 03/06/15 03/06/15 -
Caricato su

19 settembre 2012

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00057876 Treatment - Non-Protocol Therapy Form - 2047033v3.0

Inglese

No Instruction available.

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

Unnamed1

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Patient?s Name
Descrizione

Patient'sName

Tipo di dati

text

ECOG Protocol No.
Descrizione

ECOGProtocolNo.

Tipo di dati

text

ECOG Protocol No.
Descrizione

ECOGProtocolNo.

Tipo di dati

text

ECOG Patient ID
Descrizione

ECOGPatientID

Tipo di dati

text

ECOG Patient ID
Descrizione

ECOGPatientID

Tipo di dati

text

Participating Group Protocol No.
Descrizione

ParticipatingGroupProtocolNo.

Tipo di dati

text

Participating Group Patient ID
Descrizione

ParticipatingGroupPatientID

Tipo di dati

text

Institution/Affiliate
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Unnamed2
Descrizione

Unnamed2

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

AmendedDataInd

Tipo di dati

text

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

Unnamed3

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

Non-ProtocolTherapyDate,First

Tipo di dati

date

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

Type(s)offirstnon-protocoltherapy

Tipo di dati

text

Name of other non-protocol therapy:
Descrizione

OtherNon-ProtocolTherapyName

Tipo di dati

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.)
Descrizione

Wasthenon-protocoltherapygivenforthediseaseofthisprotocol?

Tipo di dati

text

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

Comments

Comments
Descrizione

Comments

Tipo di dati

text

Investigator Signature
Descrizione

InvestigatorSignature

Tipo di dati

text

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

InvestigatorSignatureDate

Tipo di dati

date

Ccrr Module For Non-protocol Therapy Form
Descrizione

Ccrr Module For Non-protocol Therapy Form

Non-protocol chemotherapy
Descrizione

Non-ProtocolChemotherapyInd

Tipo di dati

text

Non-protocol hormonal therapy
Descrizione

Non-ProtocolHormonalTherapyInd

Tipo di dati

text

Non-protocol immunotherapy/biologic response modifiers
Descrizione

Non-ProtocolImmunotherapyInd

Tipo di dati

text

Other non-protocol therapy
Descrizione

OtherTherapyInd

Tipo di dati

text

Non-protocol surgery
Descrizione

Non-protocolSurgeryPerformedInd-3

Tipo di dati

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
Descrizione

Non-ProtocolRTInd

Tipo di dati

text

Non-protocol high dose chemotherapy/stem cell transplant
Descrizione

Non-ProtocolHDC/ASCTInd

Tipo di dati

text

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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: Non-Protocol Therapy Form
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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)
CL.1
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
CL.2
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)
CL.3
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
CL.4
Code List
Non-protocol chemotherapy
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Non-protocol hormonal therapy
text
CL.5
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
CL.6
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
CL.7
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)
CL.8
Code List
Non-protocol surgery
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
Item
Non-protocol radiation therapy
text
CL.9
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
CL.10
Code List
Non-protocol high dose chemotherapy/stem cell transplant
CL Item
yes (yes)
CL Item
unknown (unknown)
CL Item
no (no)
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