ID

3455

Description

PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0618400D-589D-7445-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0618400D-589D-7445-E044-0003BA3F9857

Keywords

Versions (3)
  1. 9/20/12 9/20/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/16/15 6/16/15 -
Uploaded on

September 20, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Treatment - Breast Cancer - PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision - 2432444v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Breast Cancer - PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision
    1. No Instruction available.
Unnamed1
Description

Unnamed1

ECOG Protocol Number
Description

ProtocolECOGIdentifierNumber

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
C25491
UMLS 2011AA Property
C1512162
ECOG Patient ID
Description

PatientECOGIdentifierNumber

Data type

text

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
C25491
UMLS 2011AA Property
C1512162
DCI Name
Description

CollectedDataFormName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus ObjectClass
C25452
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
Description

ReportingEvaluationPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25214
UMLS 2011AA ObjectClass
C0220825
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C25651
UMLS 2011AA ObjectClass
C0700287
Completed By Central Lab
Description

Completed By Central Lab

Date of Diagnosis of Second Primary Cancer (mm/dd/yyyy)
Description

SecondPrimaryNeoplasmDiagnosisDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass
C25666
UMLS 2011AA ObjectClass
C0205436
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Site of Second Primary Cancer
Description

SecondPrimaryMalignantNeoplasmAnatomicSiteType

Data type

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
C25284
UMLS 2011AA ValueDomain
C0332307
Specify
Description

SecondPrimaryMalignantNeoplasmAnatomicSiteSpecify

Data type

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
C25685
UMLS 2011AA ValueDomain
C1521902
Include information on histologic subtype (s Please attach copies of any corroborating pathology reports.)
Description

SecondTumorHistologicSubtypeSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass
C25666
UMLS 2011AA ObjectClass
C0205436
NCI Thesaurus Property
C25526
UMLS 2011AA Property
C0205462
NCI Thesaurus Property
C25696
UMLS 2011AA Property
C0449560
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Comments
Description

Comments

Investigator Signature
Description

InvestigatorSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Investigator Signature Date
Description

InvestigatorSignatureDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Breast Cancer - PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
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)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientECOGIdentifierNumber
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
CollectedDataFormName
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)
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)
Item
Reporting Period
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus ObjectClass)
C0700287 (UMLS 2011AA ObjectClass)
CL.1
Code List
Reporting Period
CL Item
Second Primary Cancer (Second primary)
Item Group
Completed By Central Lab
SecondPrimaryNeoplasmDiagnosisDate
Item
Date of Diagnosis of Second Primary Cancer (mm/dd/yyyy)
date
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus ObjectClass)
C0205436 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
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)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
Site of Second Primary Cancer
CL Item
Acute Lymphocytic Leukemia (Acute Lymphocytic Leukemia (ALL))
CL Item
Acute Myelogenous Leukemia (Acute Myelogenous Leukemia (AML))
CL Item
Adrenal (Adrenal)
CL Item
Aids-related Lymphoma (AIDS-related Lymphoma)
CL Item
Anal Canal (Anal Canal)
C12375 (NCI Thesaurus)
C0227411 (UMLS 2011AA)
CL Item
Basal Cell Carcinoma (Basal Cell Carcinoma)
CL066969 (NCI Metathesaurus)
CL Item
Bladder, Urinary Tract (Bladder, Urinary Tract)
CL Item
Brain Tumor (Brain Tumor)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Breast, In Situ (Breast, in situ)
CL Item
Carcinoid (Carcinoid)
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Chronic Lymphocytic Leukemia (Chronic Lymphocytic Leukemia (CLL))
CL Item
Chronic Myelogenous Leukemia (Chronic Myelogenous Leukemia (CML))
C3174 (NCI Thesaurus)
C0023473 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Endometrium, Uterine Corpus (Endometrium, Uterine Corpus)
CL Item
Esophagus (Esophagus)
C12389 (NCI Thesaurus)
C0014876 (UMLS 2011AA)
CL Item
Gastric Cancer (Gastric Cancer)
CL Item
Hairy Cell Leukemia (Hairy Cell Leukemia)
C7402 (NCI Thesaurus)
C0023443 (UMLS 2011AA)
CL Item
Head And Neck (Head and Neck)
C12418 (NCI Thesaurus)
C0460004 (UMLS 2011AA)
CL Item
Hodgkin's Lymphoma (Hodgkin's Disease)
C9357 (NCI Thesaurus)
C0019829 (UMLS 2011AA)
CL Item
Islet Cell/carcinoid (Islet Cell/Carcinoid)
CL Item
Kaposi Sarcoma (Kaposi sarcoma)
C9087 (NCI Thesaurus)
C0036220 (UMLS 2011AA)
CL Item
Leukemia (Leukemia)
C3161 (NCI Thesaurus)
C0023418 (UMLS 2011AA)
CL Item
Liver, Gall Bladder, Bile Duct (Liver, Gall Bladder, Bile Duct)
CL Item
Lung Cancer (Lung cancer)
CL Item
Lymphoma (Lymphoma)
C3208 (NCI Thesaurus)
C0024299 (UMLS 2011AA)
CL Item
Lymphosarcoma (Lymphosarcoma)
CL Item
Melanoma (Melanoma)
C3224 (NCI Thesaurus)
C0025202 (UMLS 2011AA)
CL Item
Mesothelioma (Mesothelioma)
CL Item
Myelodysplastic Syndrome (Myelodysplastic Syndrome)
CL Item
Myeloma (Myeloma)
CL Item
Non-hodgkin's Lymphoma (Non-Hodgkin's Lymphoma)
C3211 (NCI Thesaurus)
C0024305 (UMLS 2011AA)
CL Item
Non-small Cell Lung Cancer (Non-Small Cell Lung Cancer)
CL Item
Osteosarcoma (Osteosarcoma)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Other Gyn (Other GYN)
CL Item
Other Non-melanoma Skin Cancer (Other non-melanoma skin cancer)
CL Item
Ovarian (Ovarian)
CL Item
Pancreas (Pancreas)
C12393 (NCI Thesaurus)
C0030274 (UMLS 2011AA)
CL Item
Penile (Penile)
CL Item
Pleural Effusion (Pleural effusion)
C3331 (NCI Thesaurus)
C0021071 (UMLS 2011AA)
CL Item
Promyelocytic Leukemia (Promyelocytic Leukemia (APL))
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)
CL Item
Rectum (Rectum)
C12390 (NCI Thesaurus)
C0034896 (UMLS 2011AA)
CL Item
Renal Cell (Renal Cell)
CL Item
Sarcoma (Sarcoma)
C9118 (NCI Thesaurus)
C1261473 (UMLS 2011AA)
CL Item
Small Intestine (Small Intestine)
C12386 (NCI Thesaurus)
C0021852 (UMLS 2011AA)
CL Item
Small-cell Lung Cancer (Small-Cell Lung Cancer)
CL Item
Spinal Cord (Spinal Cord)
C12464 (NCI Thesaurus)
C0037925 (UMLS 2011AA)
CL Item
Testis, Germ Cell, Seminoma (Testis, Germ Cell, Seminoma)
CL Item
Thymoma (Thymoma)
CL Item
Thyroid (Thyroid)
CL Item
Waldenstrom's Macroglobulinemia (Waldenstrom's Macroglobulinemia)
SecondPrimaryMalignantNeoplasmAnatomicSiteSpecify
Item
Specify
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)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
SecondTumorHistologicSubtypeSpecify
Item
Include information on histologic subtype (s Please attach copies of any corroborating pathology reports.)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus ObjectClass)
C0205436 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25696 (NCI Thesaurus Property)
C0449560 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Comments
InvestigatorSignatureText
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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