ID

370

Beskrivning

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

Länk

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

Nyckelord

Versioner (2)
  1. 2012-05-25 2012-05-25 -
  2. 2015-01-22 2015-01-22 - Martin Dugas
Uppladdad den

25 maj 2012

DOI

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Licens

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

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: S0100 FOLLOW UP FORM
    1. No Instruction available.
Vital Status
Beskrivning

Vital Status

Vital Status
Beskrivning

Patient'sVitalStatus

Datatyp

text

Date of last contact or death
Beskrivning

DeathDate/LastContactDate

Datatyp

date

Disease Follow Up Status
Beskrivning

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, )
Beskrivning

CancerFollow-upStatusInd

Datatyp

text

Date of Last Clinical Assessment
Beskrivning

CancerFollow-upStatusDate

Datatyp

date

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

Notice Of First Relapse Or Progression

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

Hasthepatientdevelopedafirstrelapseorprogressionthathasnotbeenpreviouslyreported?

Datatyp

text

Date of Relapse or Progression
Beskrivning

DateofRelapseorProgression

Datatyp

text

Site(s) of Relapse or Progression
Beskrivning

Site(s)ofRelapseorProgression

Datatyp

text

Notice Of New Primary
Beskrivning

Notice Of New Primary

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

NewPrimaryCancerInd

Datatyp

text

New Primary Site
Beskrivning

NewPrimarySite

Datatyp

text

Non-protocol Treatment
Beskrivning

Non-protocol Treatment

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

Non-ProtocolTherapyInd

Datatyp

text

Date of First Non-Protocol Therapy
Beskrivning

Non-ProtocolTherapyDate,First

Datatyp

date

Agents
Beskrivning

AgentName

Datatyp

text

Long Term Toxicity
Beskrivning

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,)
Beskrivning

LateAdverseEventInd

Datatyp

text

Toxicities and Grades
Beskrivning

CTCAdverseEventTerm

Datatyp

text

Notes
Beskrivning

Comments

Datatyp

text

Ccrr Module For S0100 Follow Up Form
Beskrivning

Ccrr Module For S0100 Follow Up Form

SWOG Patient ID
Beskrivning

SWOGPatientID

Datatyp

text

SWOG Study No.
Beskrivning

SWOGStudyNo.

Datatyp

text

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Patient Initials (L, F, M)
Beskrivning

PatientInitials

Datatyp

text

Institution/Affiliate
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

Physician
Beskrivning

TreatingPhysician

Datatyp

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
Beskrivning

GroupName

Datatyp

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.
Beskrivning

StudyNo.

Datatyp

text

Pt. ID
Beskrivning

Pt.ID

Datatyp

text

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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: S0100 FOLLOW UP FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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