ID

3405

Beschreibung

Late Radiation Toxicity 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=A65CC822-2E9B-42C2-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A65CC822-2E9B-42C2-E034-0003BA0B1A09

Stichworte

  1. 20.09.12 20.09.12 -
  2. 28.07.15 28.07.15 - Julian Varghese
Hochgeladen am

20. September 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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Pancreatic Cancer NCT00057876 Toxicity - Late Radiation Toxicity Form - 2045275v3.0

No Instruction available.

  1. StudyEvent: Late Radiation Toxicity Form
    1. No Instruction available.
Unnamed1
Beschreibung

Unnamed1

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Adverse Event Reporting From Date (M D Y)
Beschreibung

CTCAdverseEventReportBeginDate

Datentyp

date

Adverse Event Reporting To Date (M D Y)
Beschreibung

CTCAdverseEventReportEndDate

Datentyp

date

Patient?s Name
Beschreibung

Patient'sName

Datentyp

text

ECOG Protocol No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Protocol No.
Beschreibung

ECOGProtocolNo.

Datentyp

text

ECOG Patient ID
Beschreibung

ECOGPatientID

Datentyp

text

ECOG Patient ID
Beschreibung

ECOGPatientID

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Participating Group Patient ID
Beschreibung

ParticipatingGroupPatientID

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Unnamed2
Beschreibung

Unnamed2

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

AmendedDataInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25474 (undefined)
UMLS 2011AA ObjectClass
C1511726 (Data)
NCI Thesaurus Property
C25416 (undefined)
UMLS 2011AA Property
C1691222 (Amended)
Unnamed3
Beschreibung

Unnamed3

Unnamed (CTC Adverse Event Term)
Beschreibung

CTCAdverseEventTerm

Datentyp

text

CTC Adverse Event Grade
Beschreibung

CTCAdverseEventGrade

Datentyp

text

CTC Adverse Event Attribution Code
Beschreibung

CTCAdverseEventAttributionCode

Datentyp

text

AE Filed?
Beschreibung

ADRFiledInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25410 (undefined)
UMLS 2011AA ObjectClass
C1521800 (Adverse Drug Experience Report)
NCI Thesaurus Property
C25175 (undefined)
UMLS 2011AA Property
C1522646 (Filed)
Radiation, other; specify
Beschreibung

Radiation,other;specify

Datentyp

text

Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

Alias
NCI Thesaurus Property
C25678 (undefined)
UMLS 2011AA Property
C1519316 (Signature)
LOINC
LP248948-4
NCI Thesaurus ObjectClass
C17089 (undefined)
UMLS 2011AA ObjectClass
C0035173 (Research Personnel)
SNOMED
769038007
LOINC
LA23773-7
Date
Beschreibung

InvestigatorSignatureDate

Datentyp

date

Ccrr Module For Late Radiation Toxicity Form
Beschreibung

Ccrr Module For Late Radiation Toxicity Form

Has an expedited AE report been filed?
Beschreibung

AdverseDrugExperienceReportingSystemReportFiledInd-3

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38148 (undefined)
UMLS 2011AA ValueDomain
C1512699 (Yes, No, or Unknown Response)
NCI Thesaurus ObjectClass
C25375 (undefined)
UMLS 2011AA ObjectClass
C0684224 (Report (document))
SNOMED
229059009
LOINC
LP183761-8
NCI Metathesaurus ObjectClass
C0085425 (Adverse Drug Reaction Reporting Systems)
NCI Thesaurus Property
C25175 (undefined)
UMLS 2011AA Property
C1522646 (Filed)

Ähnliche Modelle

No Instruction available.

  1. StudyEvent: Late Radiation Toxicity Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
CTCAdverseEventReportBeginDate
Item
Adverse Event Reporting From Date (M D Y)
date
CTCAdverseEventReportEndDate
Item
Adverse Event Reporting To Date (M D Y)
date
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
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)
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
CTCAdverseEventTerm
Item
Unnamed (CTC Adverse Event Term)
text
CTCAdverseEventGrade
Item
CTC Adverse Event Grade
text
CTCAdverseEventAttributionCode
Item
CTC Adverse Event Attribution Code
text
Item
AE Filed?
text
C25410 (NCI Thesaurus ObjectClass)
C1521800 (UMLS 2011AA ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
Code List
AE Filed?
CL Item
no (no)
CL Item
yes (yes)
Radiation,other;specify
Item
Radiation, other; specify
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 Late Radiation Toxicity Form
Item
Has an expedited AE report been filed?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C0085425 (NCI Metathesaurus ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
Code List
Has an expedited AE report been filed?
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (YES)

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