ID

370

Descrizione

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

collegamento

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

Keywords

versioni (2)
  1. 25/05/12 25/05/12 -
  2. 22/01/15 22/01/15 - Martin Dugas
Caricato su

25 maggio 2012

DOI

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Licenza

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

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: S0100 FOLLOW UP FORM
    1. No Instruction available.
Vital Status
Descrizione

Vital Status

Vital Status
Descrizione

Patient'sVitalStatus

Tipo di dati

text

Date of last contact or death
Descrizione

DeathDate/LastContactDate

Tipo di dati

date

Disease Follow Up Status
Descrizione

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, )
Descrizione

CancerFollow-upStatusInd

Tipo di dati

text

Date of Last Clinical Assessment
Descrizione

CancerFollow-upStatusDate

Tipo di dati

date

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

Notice Of First Relapse Or Progression

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

Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?

Tipo di dati

text

Date of Relapse or Progression
Descrizione

DateofRelapseorProgression

Tipo di dati

text

Site(s) of Relapse or Progression
Descrizione

Site(s)ofRelapseorProgression

Tipo di dati

text

Notice Of New Primary
Descrizione

Notice Of New Primary

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

NewPrimaryCancerInd

Tipo di dati

text

New Primary Site
Descrizione

NewPrimarySite

Tipo di dati

text

Non-protocol Treatment
Descrizione

Non-protocol Treatment

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

Non-ProtocolTherapyInd

Tipo di dati

text

Date of First Non-Protocol Therapy
Descrizione

Non-ProtocolTherapyDate,First

Tipo di dati

date

Agents
Descrizione

AgentName

Tipo di dati

text

Long Term Toxicity
Descrizione

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,)
Descrizione

LateAdverseEventInd

Tipo di dati

text

Toxicities and Grades
Descrizione

CTCAdverseEventTerm

Tipo di dati

text

Notes
Descrizione

Comments

Tipo di dati

text

Ccrr Module For S0100 Follow Up Form
Descrizione

Ccrr Module For S0100 Follow Up Form

SWOG Patient ID
Descrizione

SWOGPatientID

Tipo di dati

text

SWOG Study No.
Descrizione

SWOGStudyNo.

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Patient Initials (L, F, M)
Descrizione

PatientInitials

Tipo di dati

text

Institution/Affiliate
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Physician
Descrizione

TreatingPhysician

Tipo di dati

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
Descrizione

GroupName

Tipo di dati

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.
Descrizione

StudyNo.

Tipo di dati

text

Pt. ID
Descrizione

Pt.ID

Tipo di dati

text

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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: S0100 FOLLOW UP FORM
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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