ID

2854

Description

S0205 Notice of Death S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11CBC94-4007-1D74-E034-080020C9C0E0

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11CBC94-4007-1D74-E034-080020C9C0E0

Mots-clés

Versions (3)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 03/07/2015 03/07/2015 -
Téléchargé le

19 septembre 2012

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Retour au modèle Commentaires
Groupe Item commentaires pour :

Item commentaires pour :

Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

Pancreatic Cancer NCT00075686 Follow-Up - S0205 Notice of Death - 2035606v3.0

Anglais

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulaires  
Unnamed1
Description

Unnamed1

SWOG Patient ID
Description

SWOGPatientID

Type de données

text

Most Recent SWOG Study No.
Description

SWOGStudyNo.

Type de données

text

Patient Initials (L, F M)
Description

PatientInitialsName

Type de données

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
Description

InstitutionName

Type de données

text

Affiliate
Description

AffiliateName

Type de données

text

Physician (Groups other than SWOG)
Description

RegisteredInvestigator

Type de données

text

Group Name
Description

GroupName

Type de données

text

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

StudyNo.

Type de données

text

Pt. ID
Description

Pt.ID

Type de données

text

Unnamed2
Description

Unnamed2

Date of Death (month / day / year)
Description

DeathDate/LastContactDate

Type de données

date

Causes Of Death
Description

Causes Of Death

Non-cancer and non-treatment related causes (select one)
Description

DeathReason

Type de données

text

Non-cancer and non-treatment related causes (select one)
Description

DeathReason

Type de données

text

Non-cancer and non-treatment related causes (select one)
Description

DeathReason

Type de données

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Type de données

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Type de données

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Type de données

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Type de données

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Type de données

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Type de données

text

Autopsy done?
Description

AutopsyInd

Type de données

text

Death information obtained from (select all that apply)
Description

DeathInformationSource

Type de données

text

Other, specify
Description

PatientDeathSourceSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
Notes
Description

Notes

Notes
Description

Comments

Type de données

text

Ccrr Module For S0205 Notice Of Death
Description

Ccrr Module For S0205 Notice Of Death

Retour au début de la page

Similar models

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
Most Recent SWOG Study No.
text
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)
InstitutionName
Item
Institution
text
AffiliateName
Item
Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID
text
Item Group
Unnamed2
DeathDate/LastContactDate
Item
Date of Death (month / day / year)
date
Item Group
Causes Of Death
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
Item
Autopsy done?
text
CL.5
Code List
Autopsy done?
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
Death information obtained from (select all that apply)
text
CL.6
Code List
Death information obtained from (select all that apply)
CL Item
Autopsy Was The Source Of Information On The Patient's Death (Autopsy report)
CL Item
Death Certificate Was The Source Of Information On The Patient's Death (Medical record / Death certificate)
CL Item
Physician (Physician)
CL Item
Relative or friend (Relative or friend)
CL Item
The Source Of Information On The Patient's Death Is Not On This List, Specify Other (Other, specify)
PatientDeathSourceSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
Item Group
Notes
Comments
Item
Notes
text
Item Group
Ccrr Module For S0205 Notice Of Death
Retour au début de la page 

Contact

Utilisez ce formulaire pour les retours, les questions et les améliorations suggérées.

Les champs marqués d’un * sont obligatoires.

Aide

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