ID

3373

Beskrivning

Second Primary Form Gemcitabine With or Without Radiation Therapy in Treating Patients With Pancreatic Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6239C87-FB3E-3C1F-E034-0003BA0B1A09

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6239C87-FB3E-3C1F-E034-0003BA0B1A09

Nyckelord

Versioner (3)
  1. 2012-09-20 2012-09-20 -
  2. 2015-06-02 2015-06-02 -
  3. 2015-06-03 2015-06-03 -
Uppladdad den

20 september 2012

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00057876 Follow-Up - Second Primary Form - 2047160v3.0

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: Second Primary Form
    1. No Instruction available.
Unnamed1
Beskrivning

Unnamed1

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Patient?s Name
Beskrivning

Patient'sName

Datatyp

text

ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beskrivning

ECOGProtocolNo.

Datatyp

text

ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beskrivning

ECOGProtocolNo.

Datatyp

text

ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beskrivning

ECOGPatientID

Datatyp

text

ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beskrivning

ECOGPatientID

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Participating Group Patient ID
Beskrivning

ParticipatingGroupPatientID

Datatyp

text

Institution/Affiliate
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

Unnamed2
Beskrivning

Unnamed2

Are data amended? (If yes, please circle amended items in red)
Beskrivning

AmendedDataInd

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed3
Beskrivning

Unnamed3

Date of Diagnosis of Second Primary Cancer
Beskrivning

DateofDiagnosisofSecondPrimaryCancer

Datatyp

text

Site of Second Primary Cancer
Beskrivning

SecondPrimaryMalignantNeoplasmAnatomicSiteText

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ObjectClass
C25666
UMLS 2011AA ObjectClass
C0205436
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property
C25421
UMLS 2011AA Property
C0002808
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Include information on histologic subtype(s).
Beskrivning

Includeinformationonhistologicsubtype(s).

Datatyp

text

ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beskrivning

ECOGProtocolNo.

Datatyp

text

ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beskrivning

ECOGPatientID

Datatyp

text

Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
Beskrivning

BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols

Datatyp

text

Briefly describe treatment planned or given for the diagnosis of this second primary:
Beskrivning

Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:

Datatyp

text

Comments
Beskrivning

Comments

Comments
Beskrivning

Comments

Datatyp

text

Investigator Signature
Beskrivning

InvestigatorSignature

Datatyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beskrivning

InvestigatorSignatureDate

Datatyp

date

Ccrr Module For Second Primary Form
Beskrivning

Ccrr Module For Second Primary Form

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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: Second Primary Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGProtocolNo.
Item
ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGPatientID
Item
ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGPatientID
Item
ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Unnamed2
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)
CL.1
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed3
DateofDiagnosisofSecondPrimaryCancer
Item
Date of Diagnosis of Second Primary Cancer
text
SecondPrimaryMalignantNeoplasmAnatomicSiteText
Item
Site of Second Primary Cancer
text
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus ObjectClass)
C0205436 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property)
C0002808 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Includeinformationonhistologicsubtype(s).
Item
Include information on histologic subtype(s).
text
ECOGProtocolNo.
Item
ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGPatientID
Item
ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols
Item
Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
text
Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:
Item
Briefly describe treatment planned or given for the diagnosis of this second primary:
text
Item Group
Comments
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)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Second Primary Form
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