ID

3407

Description

Nontarget Lesions Supplemental 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=A6238F51-F0B5-3C1D-E034-0003BA0B1A09

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6238F51-F0B5-3C1D-E034-0003BA0B1A09

Mots-clés

Versions (3)
  1. 20/09/2012 20/09/2012 -
  2. 02/06/2015 02/06/2015 -
  3. 03/06/2015 03/06/2015 -
Téléchargé le

20 septembre 2012

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00057876 Response - Nontarget Lesions Supplemental Form - 2047073v3.0

Anglais

No Instruction available.

1 Formulaires  
  1. StudyEvent: Nontarget Lesions Supplemental Form
    1. No Instruction available.
Unnamed1
Description

Unnamed1

Registration Step
Description

RegistrationStep

Type de données

text

Cycle Number (Use '00' for baseline; leave blank if off-treatment or N/A)
Description

CycleNumber

Type de données

text

Patient?s Name
Description

Patient'sName

Type de données

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Type de données

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Type de données

text

ECOG Patient ID
Description

ECOGPatientID

Type de données

text

ECOG Patient ID
Description

ECOGPatientID

Type de données

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Type de données

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Type de données

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Type de données

text

Unnamed2
Description

Unnamed2

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

AmendedDataInd

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Nontarget Lesions:
Description

Nontarget Lesions:

Lesion Number
Description

Lesion,ReferenceNumber

Type de données

double

Site of Lesion (Multiple nontarget lesions within an organ may be combined as a single site, but must be reported in same manner as at baseline.)
Description

Lesion,AnatomicSite

Type de données

text

Site Code
Description

LesionMeasurableEvaluationAnatomicSite

Type de données

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C37894
UMLS 2011AA Property
C1513040
Method of Evaluation
Description

AssessmentType

Type de données

text

Date of Evaluation (M D Y)
Description

AssessmentDate

Type de données

date

Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
Description

Follow-UpStatusofLesions

Type de données

text

Cytology Result (For Site Code 04 effusion/ascites ONLY)
Description

CytologyResult

Type de données

text

Alias
NCI Thesaurus ObjectClass
C16491
UMLS 2011AA ObjectClass
C0010819
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
Unequivocal progressive disease in nontarget lesions is based on: (please decribe)
Description

Unequivocalprogressivediseaseinnontargetlesionsisbasedon:(pleasedecribe)

Type de données

text

Comments
Description

Comments

Comments
Description

Comments

Type de données

text

Investigator Signature
Description

InvestigatorSignature

Type de données

text

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

InvestigatorSignatureDate

Type de données

date

Ccrr Module For Nontarget Lesions Supplemental Form
Description

Ccrr Module For Nontarget Lesions Supplemental Form

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Similar models

No Instruction available.

1 Formulaires
  1. StudyEvent: Nontarget Lesions Supplemental Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
CycleNumber
Item
Cycle Number (Use '00' for baseline; leave blank if off-treatment or N/A)
text
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
Nontarget Lesions:
Lesion,ReferenceNumber
Item
Lesion Number
double
Lesion,AnatomicSite
Item
Site of Lesion (Multiple nontarget lesions within an organ may be combined as a single site, but must be reported in same manner as at baseline.)
text
Item
Site Code
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C37894 (NCI Thesaurus Property)
C1513040 (UMLS 2011AA Property)
CL.2
Code List
Site Code
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Brain (Brain)
C12439 (NCI Thesaurus)
C0006104 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Effusion/ascites (Effusion/Ascites)
CL Item
Gi (GI)
CL Item
Gu (GU)
CL Item
Head & Neck (Head & Neck)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Nodes (Nodes)
CL Item
Skin (Skin)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item
Method of Evaluation
text
CL.3
Code List
Method of Evaluation
CL Item
Clinical Examination (Clinical Exam)
CL Item
Chest X-ray (Chest X-Ray)
CL Item
Ct Scan (CT Scan (non-spiral))
CL Item
Spiral Ct Scan (Spiral CT)
CL Item
Mri (MRI)
CL Item
Ultrasound (Ultrasound)
C64384 (NCI Thesaurus)
C1456803 (UMLS 2011AA)
CL Item
Bone Scan (Bone scan)
C17646 (NCI Thesaurus)
C0203668 (UMLS 2011AA)
CL Item
Not Evaluated (Not evaluated)
CL Item
Other (Other (specify in Comments))
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AssessmentDate
Item
Date of Evaluation (M D Y)
date
Item
Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
text
CL.4
Code List
Follow-up Status of Lesions (Choose one for each lesion. Leave blank if baseline.)
CL Item
Cr (CR)
CL Item
Incompl. Resp./sd (Incompl. resp./SD)
CL Item
Pd (PD)
Item
Cytology Result (For Site Code 04 effusion/ascites ONLY)
text
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
CL.5
Code List
Cytology Result (For Site Code 04 effusion/ascites ONLY)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
Unequivocalprogressivediseaseinnontargetlesionsisbasedon:(pleasedecribe)
Item
Unequivocal progressive disease in nontarget lesions is based on: (please decribe)
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 Nontarget Lesions Supplemental Form
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