ID

2759

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 28-05-15 28-05-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

19 september 2012

DOI

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Licentie

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

Engels

No Instruction available.

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

Unnamed1

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient?s Name
Beschrijving

Patient'sName

Datatype

text

ECOG Protocol No.
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Protocol No.
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Patient ID
Beschrijving

ECOGPatientID

Datatype

text

ECOG Patient ID
Beschrijving

ECOGPatientID

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Participating Group Patient ID
Beschrijving

ParticipatingGroupPatientID

Datatype

text

Institution/Affiliate
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Unnamed2
Beschrijving

Unnamed2

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

AmendedDataInd

Datatype

text

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

Unnamed3

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

Non-ProtocolTherapyDate,First

Datatype

date

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

Type(s)offirstnon-protocoltherapy

Datatype

text

Name of other non-protocol therapy:
Beschrijving

OtherNon-ProtocolTherapyName

Datatype

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.)
Beschrijving

Wasthenon-protocoltherapygivenforthediseaseofthisprotocol?

Datatype

text

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

Comments

Comments
Beschrijving

Comments

Datatype

text

Investigator Signature
Beschrijving

InvestigatorSignature

Datatype

text

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

InvestigatorSignatureDate

Datatype

date

Ccrr Module For Non-protocol Therapy Form
Beschrijving

Ccrr Module For Non-protocol Therapy Form

Non-protocol chemotherapy
Beschrijving

Non-ProtocolChemotherapyInd

Datatype

text

Non-protocol hormonal therapy
Beschrijving

Non-ProtocolHormonalTherapyInd

Datatype

text

Non-protocol immunotherapy/biologic response modifiers
Beschrijving

Non-ProtocolImmunotherapyInd

Datatype

text

Other non-protocol therapy
Beschrijving

OtherTherapyInd

Datatype

text

Non-protocol surgery
Beschrijving

Non-protocolSurgeryPerformedInd-3

Datatype

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
Beschrijving

Non-ProtocolRTInd

Datatype

text

Non-protocol high dose chemotherapy/stem cell transplant
Beschrijving

Non-ProtocolHDC/ASCTInd

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Non-Protocol Therapy Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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