ID

370

Description

S0100 FOLLOW UP FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB52E43-75AF-43F2-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB52E43-75AF-43F2-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 5/25/12 5/25/12 -
  2. 1/22/15 1/22/15 - Martin Dugas
Uploaded on

May 25, 2012

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia Follow-Up - S0100 FOLLOW UP FORM - 2071711v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0100 FOLLOW UP FORM
    1. No Instruction available.
Vital Status
Description

Vital Status

Vital Status
Description

Patient'sVitalStatus

Data type

text

Date of last contact or death
Description

DeathDate/LastContactDate

Data type

date

Disease Follow Up Status
Description

Disease Follow Up Status

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form? (If Yes, )
Description

CancerFollow-upStatusInd

Data type

text

Date of Last Clinical Assessment
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of First Relapse Or Progression
Description

Notice Of First Relapse Or Progression

Has the patient developed a first relapse or progression that has not been previously reported? (If Yes)
Description

Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?

Data type

text

Date of Relapse or Progression
Description

DateofRelapseorProgression

Data type

text

Site(s) of Relapse or Progression
Description

Site(s)ofRelapseorProgression

Data type

text

Notice Of New Primary
Description

Notice Of New Primary

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If Yes,)
Description

NewPrimaryCancerInd

Data type

text

New Primary Site
Description

NewPrimarySite

Data type

text

Non-protocol Treatment
Description

Non-protocol Treatment

Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported? (If Yes)
Description

Non-ProtocolTherapyInd

Data type

text

Date of First Non-Protocol Therapy
Description

Non-ProtocolTherapyDate,First

Data type

date

Agents
Description

AgentName

Data type

text

Long Term Toxicity
Description

Long Term Toxicity

Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade 3) long term toxicity that has not been previously reported? (If Yes,)
Description

LateAdverseEventInd

Data type

text

Toxicities and Grades
Description

CTCAdverseEventTerm

Data type

text

Notes
Description

Comments

Data type

text

Ccrr Module For S0100 Follow Up Form
Description

Ccrr Module For S0100 Follow Up Form

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F, M)
Description

PatientInitials

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Physician
Description

TreatingPhysician

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Group Name
Description

GroupName

Data type

text

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

StudyNo.

Data type

text

Pt. ID
Description

Pt.ID

Data type

text

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No Instruction available.

1 forms
  1. StudyEvent: S0100 FOLLOW UP FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Vital Status
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death
date
Item Group
Disease Follow Up Status
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form? (If Yes, )
text
CL.2
Code List
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form? (If Yes, )
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Notice Of First Relapse Or Progression
Item
Has the patient developed a first relapse or progression that has not been previously reported? (If Yes)
text
CL.3
Code List
Has the patient developed a first relapse or progression that has not been previously reported? (If Yes)
CL Item
No2007229 (No)
CL Item
Yes2007230 (Yes)
DateofRelapseorProgression
Item
Date of Relapse or Progression
text
Site(s)ofRelapseorProgression
Item
Site(s) of Relapse or Progression
text
Item Group
Notice Of New Primary
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If Yes,)
text
CL.4
Code List
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If Yes,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimarySite
Item
New Primary Site
text
Item Group
Non-protocol Treatment
Item
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported? (If Yes)
text
CL.5
Code List
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported? (If Yes)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolTherapyDate,First
Item
Date of First Non-Protocol Therapy
date
AgentName
Item
Agents
text
Item Group
Long Term Toxicity
Item
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade 3) long term toxicity that has not been previously reported? (If Yes,)
text
CL.6
Code List
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade 3) long term toxicity that has not been previously reported? (If Yes,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CTCAdverseEventTerm
Item
Toxicities and Grades
text
Comments
Item
Notes
text
Item Group
Ccrr Module For S0100 Follow Up Form
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F, M)
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID
text
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