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Informations:
Erreur:
ID
3258
Description
Concomitant Medication Form A Phase III, Randomized Study of Gemcitabine (Fixed-Dose Rate Infusion) and Oxaliplatin (NSC 266046) Versus Gemcitabine (Fixed-Dose Rate Infusion) Versus Gemcitabine (30-Minute Infusion) in Pancreatic Carcinoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6277C4D-6BBD-3D79-E034-0003BA0B1A09
Lien
Mots-clés
Versions (3)
- 19/09/2012 19/09/2012 - Philipp Bruland
- 09/01/2015 09/01/2015 - Martin Dugas
- 03/07/2015 03/07/2015 -
Téléchargé le
19 septembre 2012
DOI
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Licence
Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00058149 Treatment - Concomitant Medication Form - 2047658v3.0
No Instruction available.
- StudyEvent: Concomitant Medication Form
Similar models
No Instruction available.
- StudyEvent: Concomitant Medication Form
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Prot. No.
text
ECOGProtocolNo.
Item
ECOG Prot. No.
text
ECOGPatientID
Item
ECOG Patient Seq. No.
text
ECOGPatientID
Item
ECOG Patient Seq. No.
text
ParticipatingGroupProtocolNo.
Item
Participating Group Prot. No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID No.
text
StepNo.
Item
Step No.
text
ParticipatingGroupName
Item
Group
text
InstitutionName
Item
Institution
text
Network
Item
Network
text
AffiliateName
Item
Affiliate
text
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)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
IntervalReportFromDate
Item
Reporting period Start Date: (M D Y)
date
IntervalReportToDate
Item
Reporting period End Date: (M D Y)
date
AgentName
Item
Generic Name (Use brand or trade if generic name unknown)
text
Dose
Item
Dose
double
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
CL Item
capsules (caps) (capsules (caps))
CL Item
gram (gm) (gram (gm))
CL Item
drops (gtts) (drops (gtts))
CL Item
inch (inch) (inch (inch))
CL Item
kilogram (kg) (kilogram (kg))
CL Item
liter (l) (liter (l))
CL Item
microgram (mcg) (microgram (mcg))
CL Item
milliequivalent (mEq) (milliequivalent (mEq))
CL Item
milligram (mg) (milligram (mg))
CL Item
milliliter (ml) (milliliter (ml))
CL Item
ounce (oz) (ounce (oz))
CL Item
tablets (tabs) (tablets (tabs))
CL Item
tablespoon (tbsp) (tablespoon (tbsp))
CL Item
teaspoon (tsp) (teaspoon (tsp))
CL Item
unit (u) (unit (u))
CL Item
other, specify (other, specify)
other,specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
other,specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
other,specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL Item
Immediately (stat) (immediately (Stat))
CL Item
As Needed (p.r.n) (as needed (P.R.N))
CL Item
Every Day (q.d.) (every day (Q.D.))
CL Item
Every Other Day (q.o.d.) (every other day (Q.O.D.))
CL Item
Twice A Day (b.i.d) (twice a day (B.I.D))
CL Item
Three Times A Day (t.i.d) (three times a day (T.I.D))
CL Item
Four Times A Day (q.i.d) (four times a day (Q.I.D))
CL Item
Twice A Week (b.i.w) (twice a week (B.I.W))
CL Item
Three Times A Week (t.i.w) (three times a week (T.I.W))
CL Item
Before Meals (a.c.) (before meals (A.C.))
CL Item
After Meals (p.c.) (after meals (P.C.))
CL Item
At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep (H.S.))
CL Item
Every 4 Hours (q4hr) (every 4 hours (Q4hr))
CL Item
Every 6 Hours (q6hr) (every 6 hours (Q6hr))
CL Item
Every 8 Hours (q8hr) (every 8 hours (Q8hr))
CL Item
Every 12 Hours (q12hr) (every 12 hours (Q12hr))
CL Item
Other, Specify (other, specify)
CL Item
Oral Administration Of Drug (oral (p.o.))
CL Item
subcutaneous (s.c.) (subcutaneous (s.c.))
CL Item
Intramuscular Administration Of Drug (intramuscular (i.m.))
CL Item
Intravenous Administration Of Drug (intravenous (i.v.))
CL Item
rectal (rectal)
CL Item
topical (topical)
CL Item
nasal (nasal)
CL Item
inhaled (inhaled)
CL Item
transdermal (transdermal)
CL Item
sublingual (sublingual)
CL Item
intradermal (intradermal)
CL Item
other, specify (other, specify)
AgentBeginDate
Item
Start Date (Leave blank if continuing from a prior report period)
date
Item
Is this medication continuing?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
AgentEndDate
Item
Stop Date (Leave blank if continuing)
date
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)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
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)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
DCIName
Item
DCI Name
text