ProtocolECOGIdentifierNumber

Item

ECOG Protocol Number

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)

PatientECOGIdentifierNumber

Item

ECOG Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)

CollectedDataFormName

Item

DCI Name

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)

RegistrationStepNumber

Item

Registration Step

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C1514821 (UMLS 2011AA ObjectClass)
C16154 (NCI Thesaurus Property)
C1704379 (UMLS 2011AA Property)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)

PatientInitialsName

Item

Patient Initials

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)

ProtocolECOGIdentifierNumber

Item

ECOG Protocol Number

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)

PatientECOGIdentifierNumber

Item

ECOG Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)

ProtocolParticipatingIdentifierNumber

Item

Participating Group Protocol Number

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

PatientParticipatingIdentifierNumber

Item

Participating Group Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

CombinedInstitutionName

Item

Institution/Affiliate

text

C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)

DataAmendedText

Item

Please mark an 'X' if data have been amended. (Please circle amended items in red)

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)

DataAmendedDate

Item

Date data amended (s - MM/DD/YYYY)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)

TreatmentEvaluationPeriodType

Item

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)

CL.4

Code List

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

CL Item

Cycle 15 Step 2 (Cycle 15 Step 2)

CL Item

Cycle 16-step 2 (Cycle 16-Step 2)

CL Item

Cycle 17 Step 2 (Cycle 17 Step 2)

CL Item

Cycle 18-step 2 (Cycle 18-Step 2)

CL Item

Cycle 19 Step 2 (Cycle 19 Step 2)

CL Item

Cycle 20-step 2 (Cycle 20-Step 2)

CL Item

Cycle 21 Step 2 (Cycle 21 Step 2)

CL Item

Cycle 22-step 2 (Cycle 22-Step 2)

CL Item

> Cycle 22 Step 2 (> Cycle 22 Step 2)

TreatmentEvaluationPeriodType

Item

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)

CL.4

Code List

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

CL Item

Cycle 15 Step 2 (Cycle 15 Step 2)

CL Item

Cycle 16-step 2 (Cycle 16-Step 2)

CL Item

Cycle 17 Step 2 (Cycle 17 Step 2)

CL Item

Cycle 18-step 2 (Cycle 18-Step 2)

CL Item

Cycle 19 Step 2 (Cycle 19 Step 2)

CL Item

Cycle 20-step 2 (Cycle 20-Step 2)

CL Item

Cycle 21 Step 2 (Cycle 21 Step 2)

CL Item

Cycle 22-step 2 (Cycle 22-Step 2)

CL Item

> Cycle 22 Step 2 (> Cycle 22 Step 2)

TreatmentEvaluationPeriodType

Item

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)

CL.4

Code List

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

CL Item

Cycle 15 Step 2 (Cycle 15 Step 2)

CL Item

Cycle 16-step 2 (Cycle 16-Step 2)

CL Item

Cycle 17 Step 2 (Cycle 17 Step 2)

CL Item

Cycle 18-step 2 (Cycle 18-Step 2)

CL Item

Cycle 19 Step 2 (Cycle 19 Step 2)

CL Item

Cycle 20-step 2 (Cycle 20-Step 2)

CL Item

Cycle 21 Step 2 (Cycle 21 Step 2)

CL Item

Cycle 22-step 2 (Cycle 22-Step 2)

CL Item

> Cycle 22 Step 2 (> Cycle 22 Step 2)

TreatmentEvaluationPeriodType

Item

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)

CL.4

Code List

On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)

CL Item

Cycle 15 Step 2 (Cycle 15 Step 2)

CL Item

Cycle 16-step 2 (Cycle 16-Step 2)

CL Item

Cycle 17 Step 2 (Cycle 17 Step 2)

CL Item

Cycle 18-step 2 (Cycle 18-Step 2)

CL Item

Cycle 19 Step 2 (Cycle 19 Step 2)

CL Item

Cycle 20-step 2 (Cycle 20-Step 2)

CL Item

Cycle 21 Step 2 (Cycle 21 Step 2)

CL Item

Cycle 22-step 2 (Cycle 22-Step 2)

CL Item

> Cycle 22 Step 2 (> Cycle 22 Step 2)

TreatmentEvaluationPeriodCycleSpecify

Item

Specify Cycle

text

C15368 (NCI Thesaurus ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25472 (NCI Thesaurus ValueDomain)
C1511572 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus ValueDomain)
C2745955 (UMLS 2011AA ValueDomain)

TreatmentEvaluationPeriodCycleSpecify

Item

Specify Cycle

text

C15368 (NCI Thesaurus ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25472 (NCI Thesaurus ValueDomain)
C1511572 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus ValueDomain)
C2745955 (UMLS 2011AA ValueDomain)

PersonOff-TreatmentTimePeriodType

Item

Off Treatment Report Period (since registration - Choose one x)

text

C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25601 (NCI Thesaurus Property)
C1518544 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property)
C0040223 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.5

Code List

Off Treatment Report Period (since registration - Choose one x)

CL Item

3 Months (3 months post registration)

CL Item

6 Months (6 months post registration)

CL Item

9 Months (9 months post registration)

CL Item

12 Months (12 months post registration)

CL Item

15 Months (15 months post registration)

CL Item

18 Months (18 months post registration)

CL Item

21 Months Post Registration (21 months post registration)

CL Item

24 Months (24 months post registration)

CL Item

30 Months (30 months post registration)

CL Item

3 Years (36 months post registration)

CL Item

42 Months Post Registration (42 Months Post Registration)

CL Item

4 Years (48 months post registration)

CL Item

54 Months Post Registration (54 Months Post Registration)

CL Item

5 Years (60 months post registration)

CL Item

6 Years (72 months post registration)

CL Item

84 Months Post Registration (84 months post registration)

CL Item

8 Years (96 months post registration)

CL Item

9 Years (108 months post registration)

CL Item

10 Years (120 months post registration)

CL Item

11 Years Post Registration (132 Months Post Registration)

CL Item

12 Years Post Registration (144 Months Post Registration)

CL Item

13 Years Post Registration (156 Months Post Registration)

CL Item

14 Years Post Registration (168 Months Post Registration)

CL Item

15 Years Post Registration (180 Months Post Registration)

PatientProstate-SpecificAntigenAssessmentInd-2

Item

Was patients PSA assessed (this report period)

text

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C17525 (NCI Thesaurus Property)
C0138741 (UMLS 2011AA Property)

CL.6

Code List

Was patients PSA assessed (this report period)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

LaboratoryProcedureProstate-SpecificAntigenTumorMarkerResultValue

Item

PSA Value (total) (ng/ml)

double

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C17525 (NCI Thesaurus Property)
C0138741 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C17220 (NCI Thesaurus Property)
C0041365 (UMLS 2011AA Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)

LaboratoryProcedureProstate-SpecificAntigenTumorMarkerResultDate

Item

Date of PSA Assessment (MM/DD/YYYY)

date

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C17525 (NCI Thesaurus Property)
C0138741 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C17220 (NCI Thesaurus Property)
C0041365 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

ClinicalProgressionAssessedInd-2

Item

Was patient assessed for clinical progression this report period

text

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25398 (NCI Thesaurus ObjectClass)
C0205210 (UMLS 2011AA ObjectClass)
C25331 (NCI Thesaurus ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)

CL.7

Code List

Was patient assessed for clinical progression this report period

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

LesionDocumentedAppearanceInd-2

Item

Was the appearance of any new lesions documented (If yes: - NEW LESIONS)

text

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25377 (NCI Thesaurus Property)
C0700364 (UMLS 2011AA Property)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)

CL.8

Code List

Was the appearance of any new lesions documented (If yes: - NEW LESIONS)

CL Item

No (no)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

LesionSiteNumber

Item

Lesion Number

double

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)

LesionSite

Item

Site of Lesion (Comments - Multiple nontarget lesions within an organ may be combined as a single site; report in a consistent manner on subsequent forms.)

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)

LesionMeasurableEvaluationAnatomicSite

Item

Site Code

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C37894 (NCI Thesaurus Property)
C1513040 (UMLS 2011AA Property)

CL.9

Code List

Site Code

CL Item

Bone (bone)

C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)

CL Item

Brain (Brain)

C12439 (NCI Thesaurus)
C0006104 (UMLS 2011AA)

CL Item

Breast (Breast)

C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)

CL Item

Effusion/ascites (Effusion/Ascites)

CL Item

Gi (GI)

CL Item

Gu (GU)

CL Item

Head & Neck (Head & Neck)

CL Item

Liver (Liver)

C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)

CL Item

Lung (Lung)

C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)

CL Item

Nodes (Nodes)

CL Item

Skin (Skin)

C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)

CL Item

Other (other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

AssessmentMethodType

Item

Method of Evaluation

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)

CL.10

Code List

Method of Evaluation

CL Item

Clinical (Clinical Examination)

C25398 (NCI Thesaurus)
C0205210 (UMLS 2011AA)

CL Item

Chest X-ray (Chest X-Ray)

CL Item

Ct Scan (CT Scan)

CL Item

Spiral Ct Scan (Spiral CT scan)

CL Item

Mri (MRI)

CL Item

Ultrasound (Ultrasound)

C64384 (NCI Thesaurus)
C1456803 (UMLS 2011AA)

CL Item

Bone Scan (Bone scan)

C17646 (NCI Thesaurus)
C0203668 (UMLS 2011AA)

CL Item

Other (other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

LesionAssessmentDate

Item

Date of Evaluation (MM/DD/YYYY)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)

CytologyResultType

Item

Cytology Result (For site code 04 effusion/ascites ONLY)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)

CL.11

Code List

Cytology Result (For site code 04 effusion/ascites ONLY)

CL Item

Negative (Negative)

C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)

CL Item

Positive (Positive)

C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)

CL Item

Not Done (Not done)

CL281691 (NCI Metathesaurus)

BoneScanMedicalImagingConfirmedAssessmentInd-2

Item

Confirmatory scan done (If Bone lesions:)

text

C17646 (NCI Thesaurus ObjectClass)
C0203668 (UMLS 2011AA ObjectClass)
C16831 (NCI Thesaurus ObjectClass)
C25458 (NCI Thesaurus Property)
C0750484 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

CL.12

Code List

Confirmatory scan done (If Bone lesions:)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

BoneScanMedicalImagingAssessmentDate

Item

Date of Scans (MM/DD/YYYY)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C17646 (NCI Thesaurus ObjectClass)
C0203668 (UMLS 2011AA ObjectClass)
C16831 (NCI Thesaurus ObjectClass)

ResponseSymptomaticDeteriorationInd-3

Item

Is there Symptomatic Deterioration of the patient's health status requiring discontinuation of treatment?

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C25269 (NCI Thesaurus Property)
C0231220 (UMLS 2011AA Property)
C25751 (NCI Thesaurus Property)
C0868945 (UMLS 2011AA Property)

CL.13

Code List

Is there Symptomatic Deterioration of the patient's health status requiring discontinuation of treatment?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

ResponseSymptomaticDeteriorationSpecify

Item

Symptomatic Deterioration Specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C25269 (NCI Thesaurus Property)
C0231220 (UMLS 2011AA Property)
C25751 (NCI Thesaurus Property)
C0868945 (UMLS 2011AA Property)

ResponseSymptomaticDeteriorationDate

Item

Symptomatic Deterioration Date (MM/DD/YYYY)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C25269 (NCI Thesaurus Property)
C0231220 (UMLS 2011AA Property)
C25751 (NCI Thesaurus Property)
C0868945 (UMLS 2011AA Property)

ResearchCommentsText

Item

Comments

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)

InvestigatorSignatureText

Item

Investigator Signature

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)

InvestigatorSignatureDate

Item

Investigator Signature Date

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files.

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