Inglês

Instructions: For each registration step, submit this form within 2 weeks after completion (or discontinuation) of treatment.

1 Formulários  
Unnamed1
Descrição

Unnamed1

SWOG Patient ID
Descrição

SWOGPatientID

Tipo de dados

text

SWOG Study No.
Descrição

SWOGStudyNo.

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Patient Initials (L, F M)
Descrição

PatientInitialsName

Tipo de dados

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
Descrição

InstitutionName

Tipo de dados

text

Affiliate
Descrição

AffiliateName

Tipo de dados

text

Physician (Groups other than SWOG)
Descrição

RegisteredInvestigator

Tipo de dados

text

Group Name
Descrição

GroupName

Tipo de dados

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.
Descrição

StudyNo.

Tipo de dados

text

Pt. ID
Descrição

Pt.ID

Tipo de dados

text

Unnamed2
Descrição

Unnamed2

Treatment Start Date
Descrição

TreatmentStartDate

Tipo de dados

date

Treatment End Date
Descrição

TreatmentEndDate

Tipo de dados

date

Regimen or Procedure or Site(s)
Descrição

RegimenorProcedureorSite(s)

Tipo de dados

text

Off Treatment Reason (select one)
Descrição

OffTreatmentReason

Tipo de dados

text

Patient refused, due to toxicity, specify
Descrição

OffTreatmentReason,Toxicity

Tipo de dados

text

Patient refused, due to toxicity, specify
Descrição

OffTreatmentReason,Toxicity

Tipo de dados

text

Sites
Descrição

ProgressionSite,Other

Tipo de dados

text

Other, specify (Off Treatment Date)
Descrição

OffTreatmentReason,Other

Tipo de dados

text

Other, specify (Off Treatment Date)
Descrição

OffTreatmentReason,Other

Tipo de dados

text

Date of completion, progression, death or decision to discontinue therapy
Descrição

OffTreatmentDate

Tipo de dados

date

Will patient receive further treatment?
Descrição

FurtherTreatmentInd

Tipo de dados

text

Yes, specify
Descrição

Yes,specify

Tipo de dados

text

Date of Last Contact (or death)
Descrição

DeathDate/LastContactDate

Tipo de dados

date

Vital Status
Descrição

Patient'sVitalStatus

Tipo de dados

text

Notes
Descrição

Notes

Notes
Descrição

Comments

Tipo de dados

text

Ccrr Module For S0205 Off Treatment Notice
Descrição

Ccrr Module For S0205 Off Treatment Notice

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Similar models

Instructions: For each registration step, submit this form within 2 weeks after completion (or discontinuation) of treatment.

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
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
TreatmentStartDate
Item
Treatment Start Date
date
TreatmentEndDate
Item
Treatment End Date
date
RegimenorProcedureorSite(s)
Item
Regimen or Procedure or Site(s)
text
Item
Off Treatment Reason (select one)
text
CL.1
Code List
Off Treatment Reason (select one)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Medically required, due to toxicity, specify (Medically required, due to toxicity, specify)
CL Item
Patient refused, due to toxicity, specify (Patient refused, due to toxicity, specify)
CL Item
Patient refused, other than toxicity, specify (Patient refused, other than toxicity, specify)
CL Item
Progression or relapse (Progression or relapse)
CL Item
Death (Death)
CL Item
Other, Specify (Other, specify)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death On Study (Death on study)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Disease Progression, Relapse Prior To Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Toxicity/side Effects/complications (Toxicity/Side effects/Complications)
OffTreatmentReason,Toxicity
Item
Patient refused, due to toxicity, specify
text
OffTreatmentReason,Toxicity
Item
Patient refused, due to toxicity, specify
text
ProgressionSite,Other
Item
Sites
text
OffTreatmentReason,Other
Item
Other, specify (Off Treatment Date)
text
OffTreatmentReason,Other
Item
Other, specify (Off Treatment Date)
text
OffTreatmentDate
Item
Date of completion, progression, death or decision to discontinue therapy
date
Item
Will patient receive further treatment?
text
CL.2
Code List
Will patient receive further treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, specify (Yes, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Yes,specify
Item
Yes, specify
text
DeathDate/LastContactDate
Item
Date of Last Contact (or death)
date
Item
Vital Status
text
CL.3
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
Notes
Comments
Item
Notes
text
Item Group
Ccrr Module For S0205 Off Treatment Notice
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