ID

3405

Descripción

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

Palabras clave

Versiones (2)
  1. 20/9/12 20/9/12 -
  2. 28/7/15 28/7/15 - Julian Varghese
Subido en

20 de septiembre de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
Comentarios del modelo :

Puede comentar sobre el modelo de datos aquí. A través de las burbujas de diálogo en los grupos de elementos y elementos, puede agregar comentarios específicos.

Volver a los comentarios del modelo
Comentarios de grupo de elementos para :

Comentarios del elemento para :

Para descargar modelos de datos, debe haber iniciado sesión. Por favor iniciar sesión o Registrate gratis.

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

Inglés

No Instruction available.

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

Unnamed1

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Adverse Event Reporting From Date (M D Y)
Descripción

CTCAdverseEventReportBeginDate

Tipo de datos

date

Adverse Event Reporting To Date (M D Y)
Descripción

CTCAdverseEventReportEndDate

Tipo de datos

date

Patient?s Name
Descripción

Patient'sName

Tipo de datos

text

ECOG Protocol No.
Descripción

ECOGProtocolNo.

Tipo de datos

text

ECOG Protocol No.
Descripción

ECOGProtocolNo.

Tipo de datos

text

ECOG Patient ID
Descripción

ECOGPatientID

Tipo de datos

text

ECOG Patient ID
Descripción

ECOGPatientID

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Participating Group Patient ID
Descripción

ParticipatingGroupPatientID

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Unnamed2
Descripción

Unnamed2

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

AmendedDataInd

Tipo de datos

text

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

Unnamed3

Unnamed (CTC Adverse Event Term)
Descripción

CTCAdverseEventTerm

Tipo de datos

text

CTC Adverse Event Grade
Descripción

CTCAdverseEventGrade

Tipo de datos

text

CTC Adverse Event Attribution Code
Descripción

CTCAdverseEventAttributionCode

Tipo de datos

text

AE Filed?
Descripción

ADRFiledInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25410
UMLS 2011AA ObjectClass
C1521800
NCI Thesaurus Property
C25175
UMLS 2011AA Property
C1522646
Radiation, other; specify
Descripción

Radiation,other;specify

Tipo de datos

text

Comments
Descripción

Comments

Comments
Descripción

Comments

Tipo de datos

text

Investigator Signature
Descripción

InvestigatorSignature

Tipo de datos

text

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

InvestigatorSignatureDate

Tipo de datos

date

Ccrr Module For Late Radiation Toxicity Form
Descripción

Ccrr Module For Late Radiation Toxicity Form

Has an expedited AE report been filed?
Descripción

AdverseDrugExperienceReportingSystemReportFiledInd-3

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Metathesaurus ObjectClass
C0085425
NCI Thesaurus Property
C25175
UMLS 2011AA Property
C1522646
Volver a la parte superior de la página

Similar models

No Instruction available.

1 formularios
  1. StudyEvent: Late Radiation Toxicity Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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)
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
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)
CL.2
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)
CL.3
Code List
Has an expedited AE report been filed?
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (YES)
Volver a la parte superior de la página 

Contacto

Utilice este formulario para comentarios, preguntas y sugerencias.

Los campos marcados con * son obligatorios.

Ayuda

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial