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3387

Description

Southwest Oncology Group S0518 Hypertension Status Form Octreotide and Interferon Alfa-2b or Bevacizumab in Treating Patients With Metastatic or Locally Advanced, High-Risk Neuroendocrine Tumor Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=38429791-B8E2-1FFB-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=38429791-B8E2-1FFB-E044-0003BA3F9857

Keywords

Versions (4)
  1. 9/20/12 9/20/12 -
  2. 8/8/14 8/8/14 - Martin Dugas
  3. 1/8/15 1/8/15 - Martin Dugas
  4. 6/8/15 6/8/15 -
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September 20, 2012

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    Neuroendocrine Carcinoma NCT00569127 On-Study - Southwest Oncology Group S0518 Hypertension Status Form - 2674433v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Southwest Oncology Group S0518 Hypertension Status Form
      1. No Instruction available.
    Unnamed1
    Description

    Unnamed1

    SWOG Patient ID
    Description

    PatientSouthwestOncologyGroupIdentifierNumber

    Data type

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25699
    UMLS 2011AA Property
    C1519429
    SWOG Study No.
    Description

    ProtocolSWOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25699
    UMLS 2011AA Property
    C1519429
    Registration Step
    Description

    RegistrationStepNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C16154
    UMLS 2011AA Property
    C1704379
    NCI Thesaurus ValueDomain
    C16154
    UMLS 2011AA ValueDomain
    C1704379
    Reporting Period Start Date
    Description

    TreatmentReportingPeriodBeginDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus Property
    C25651
    UMLS 2011AA Property
    C0700287
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25431
    UMLS 2011AA ValueDomain
    C0439659
    Patient Initials (L, F M)
    Description

    PatientInitialsName

    Data type

    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/Affiliate
    Description

    CombinedInstitutionName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS 2011AA ObjectClass
    C0205195
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    Physician
    Description

    RegisteredInvestigatorName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    NCI Thesaurus ObjectClass
    C25644
    Participating Group Name
    Description

    ParticipatingGroupName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25608
    UMLS 2011AA ObjectClass
    C0679823
    NCI Thesaurus ObjectClass
    C17005
    UMLS 2011AA ObjectClass
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Study No.
    Description

    ProtocolParticipatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Patient ID (Instructions: Please complete this form after each cycle 1 cycle = 4 weeks. All dates are MONTH, DAY, YEAR. Explain any blank dates or fields in a Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form.)
    Description

    PatientParticipatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Unnamed2
    Description

    Unnamed2

    Date of most recent blood pressure assessment
    Description

    BloodPressurePhysicalExaminationMostRecentDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C54706
    UMLS 2011AA ObjectClass
    C0005823
    NCI Thesaurus ValueDomain
    C25577
    UMLS 2011AA ValueDomain
    C1513491
    Blood Pressure, Systolic
    Description

    BloodSystolicPressureMeasurement

    Data type

    double

    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus ObjectClass
    C25298
    UMLS 2011AA ObjectClass
    C0871470
    Blood pressure, Diastolic
    Description

    DiastolicBloodPressureEvaluationMeasurement

    Data type

    double

    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus ObjectClass
    C25299
    UMLS 2011AA ObjectClass
    C0428883
    Does the patient have hypertension requiring medication?
    Description

    AntihypertensiveAgentAdministeredInd-2

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C270
    UMLS 2011AA ObjectClass
    C0003364
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Agent Name
    Description

    AgentName

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus ValueDomain
    C1708
    UMLS 2011AA ValueDomain
    C0450442
    NCI Thesaurus ValueDomain
    C42614
    UMLS 2011AA ValueDomain
    C0027365
    Total Daily Dose of Agent (or Drug)
    Description

    DailyAgentTotalDose

    Data type

    double

    Alias
    NCI Thesaurus ObjectClass
    C25473
    UMLS 2011AA ObjectClass
    C0332173
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus Property
    C25304
    UMLS 2011AA Property
    C0439810
    NCI Thesaurus Property
    C25256
    UMLS 2011AA Property
    C1265611
    NCI Thesaurus ValueDomain
    C25488
    UMLS 2011AA ValueDomain
    C0178602
    NCI Thesaurus ValueDomain
    C1708
    UMLS 2011AA ValueDomain
    C0450442
    Comments
    Description

    Comments

    Comments
    Description

    ResearchCommentsText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: Southwest Oncology Group S0518 Hypertension Status Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Unnamed1
    PatientSouthwestOncologyGroupIdentifierNumber
    Item
    SWOG Patient ID
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property)
    C1519429 (UMLS 2011AA Property)
    ProtocolSWOGIdentifierNumber
    Item
    SWOG Study No.
    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)
    C25699 (NCI Thesaurus Property)
    C1519429 (UMLS 2011AA Property)
    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)
    TreatmentReportingPeriodBeginDate
    Item
    Reporting Period Start Date
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25651 (NCI Thesaurus Property)
    C0700287 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25431 (NCI Thesaurus ValueDomain)
    C0439659 (UMLS 2011AA ValueDomain)
    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)
    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)
    RegisteredInvestigatorName
    Item
    Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
    C25644 (NCI Thesaurus ObjectClass)
    ParticipatingGroupName
    Item
    Participating Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25608 (NCI Thesaurus ObjectClass)
    C0679823 (UMLS 2011AA ObjectClass)
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolParticipatingIdentifierNumber
    Item
    Participating Study No.
    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 Patient ID (Instructions: Please complete this form after each cycle 1 cycle = 4 weeks. All dates are MONTH, DAY, YEAR. Explain any blank dates or fields in a Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form.)
    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)
    Item Group
    Unnamed2
    BloodPressurePhysicalExaminationMostRecentDate
    Item
    Date of most recent blood pressure assessment
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C54706 (NCI Thesaurus ObjectClass)
    C0005823 (UMLS 2011AA ObjectClass)
    C25577 (NCI Thesaurus ValueDomain)
    C1513491 (UMLS 2011AA ValueDomain)
    BloodSystolicPressureMeasurement
    Item
    Blood Pressure, Systolic
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C25298 (NCI Thesaurus ObjectClass)
    C0871470 (UMLS 2011AA ObjectClass)
    DiastolicBloodPressureEvaluationMeasurement
    Item
    Blood pressure, Diastolic
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C25299 (NCI Thesaurus ObjectClass)
    C0428883 (UMLS 2011AA ObjectClass)
    Item
    Does the patient have hypertension requiring medication?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C270 (NCI Thesaurus ObjectClass)
    C0003364 (UMLS 2011AA ObjectClass)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    CL.1
    Code List
    Does the patient have hypertension requiring medication?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    AgentName
    Item
    Agent Name
    text
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C0450442 (UMLS 2011AA ValueDomain)
    C42614 (NCI Thesaurus ValueDomain)
    C0027365 (UMLS 2011AA ValueDomain)
    DailyAgentTotalDose
    Item
    Total Daily Dose of Agent (or Drug)
    double
    C25473 (NCI Thesaurus ObjectClass)
    C0332173 (UMLS 2011AA ObjectClass)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C25304 (NCI Thesaurus Property)
    C0439810 (UMLS 2011AA Property)
    C25256 (NCI Thesaurus Property)
    C1265611 (UMLS 2011AA Property)
    C25488 (NCI Thesaurus ValueDomain)
    C0178602 (UMLS 2011AA ValueDomain)
    C1708 (NCI Thesaurus ValueDomain)
    C0450442 (UMLS 2011AA ValueDomain)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
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