ID

3147

Descripción

S0205 Follow Up Form 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=A11B693E-8E8F-02FA-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11B693E-8E8F-02FA-E034-080020C9C0E0

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 3/7/15 3/7/15 -
Subido en

19 de septiembre de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00075686 Follow-Up - S0205 Follow Up Form - 2035701v3.0

Inglés

Instructions: Please submit at each follow up after completion of treatment until recurrence, at time of recurrence, and at protocol specified intervals after recurrence. All dates are MONTH, DAY, YEAR. Answer all questions and explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 formularios  
Unnamed1
Descripción

Unnamed1

SWOG Patient ID
Descripción

SWOGPatientID

Tipo de datos

text

SWOG Study No.
Descripción

SWOGStudyNo.

Tipo de datos

text

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Patient Initials (L, F M)
Descripción

PatientInitialsName

Tipo de datos

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
Descripción

InstitutionName

Tipo de datos

text

Affiliate
Descripción

AffiliateName

Tipo de datos

text

Physician (Groups other than SWOG)
Descripción

RegisteredInvestigator

Tipo de datos

text

Group Name
Descripción

GroupName

Tipo de datos

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.
Descripción

StudyNo.

Tipo de datos

text

Pt. ID (VITAL STATUS)
Descripción

Pt.ID

Tipo de datos

text

Unnamed2
Descripción

Unnamed2

Vital Status
Descripción

Patient'sVitalStatus

Tipo de datos

text

Date of last contact or death (DISEASE FOLLOW UP STATUS)
Descripción

DeathDate/LastContactDate

Tipo de datos

date

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Descripción

CancerFollow-upStatusInd

Tipo de datos

text

If Yes, Date of Last Clinical Assessment (NOTICE OF FIRST RELAPSE OR PROGRESSION)
Descripción

CancerFollow-upStatusDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Has the patient developed a first relapse or progression that has not been previously reported
Descripción

DiseaseRelapseProgressionInd-3

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C38155
UMLS 2011AA Property
C0277556
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus Property
C19987
UMLS 2011AA Property
C0242656
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
If Yes, Date of Relapse or Progression
Descripción

ProgressionDate

Tipo de datos

date

Site(s) of Relapse or Progression (NOTICE OF NEW PRIMARY)
Descripción

ProgressionSite

Tipo de datos

text

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Descripción

NewPrimaryCancerInd

Tipo de datos

text

If Yes, Date of Diagnosis
Descripción

NewPrimaryCancerDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site (FURTHER TREATMENT)
Descripción

NewPrimarySite

Tipo de datos

text

Has the patient received further (non-protocol) treatment for this cancer?
Descripción

Non-ProtocolTherapyInd

Tipo de datos

text

Specify Regimen (Note: If multiple regimens were received, please specify only the first regiment received after going off protocol treatment.)
Descripción

Non-ProtocolTherapyType

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass
C2167
UMLS 2011AA ObjectClass
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Comments
Descripción

Comments

Comments
Descripción

Comments

Tipo de datos

text

Ccrr Module For S0205 Follow Up Form
Descripción

Ccrr Module For S0205 Follow Up Form

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Similar models

Instructions: Please submit at each follow up after completion of treatment until recurrence, at time of recurrence, and at protocol specified intervals after recurrence. All dates are MONTH, DAY, YEAR. Answer all questions and explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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 (VITAL STATUS)
text
Item Group
Unnamed2
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death (DISEASE FOLLOW UP STATUS)
date
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
text
CL.2
Code List
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
If Yes, Date of Last Clinical Assessment (NOTICE OF FIRST RELAPSE OR PROGRESSION)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Has the patient developed a first relapse or progression that has not been previously reported
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C38155 (NCI Thesaurus Property)
C0277556 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C19987 (NCI Thesaurus Property)
C0242656 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.3
Code List
Has the patient developed a first relapse or progression that has not been previously reported
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate
Item
If Yes, Date of Relapse or Progression
date
ProgressionSite
Item
Site(s) of Relapse or Progression (NOTICE OF NEW PRIMARY)
text
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
text
CL.4
Code List
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimaryCancerDate
Item
If Yes, Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site (FURTHER TREATMENT)
text
Item
Has the patient received further (non-protocol) treatment for this cancer?
text
CL.5
Code List
Has the patient received further (non-protocol) treatment for this cancer?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolTherapyType
Item
Specify Regimen (Note: If multiple regimens were received, please specify only the first regiment received after going off protocol treatment.)
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass)
C1443775 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0205 Follow Up Form
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