ID
43020
Description
Ovarian Function Suppression Form (Form 24-OFS) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70C65E9-F1BA-21F5-E034-0003BA12F5E7
Link
Keywords
Versions (3)
- 8/27/12 8/27/12 -
- 1/9/15 1/9/15 - Martin Dugas
- 9/17/21 9/17/21 -
Uploaded on
September 17, 2021
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Ovarian Function Suppression Form (Form 24-OFS) - 2080631v3.0
OVARIAN FUNCTION SUPPRESSION FORM (Form 24-OFS) Instructions: This form is to be completed and submitted for patients randomized to Ovarian Function Suppression (OFS) and for patients who were not randomized to receive OFS but received it. Submit this form at each follow-up period (every three months in Year 1, every six months in Years 2-6) until the completion of OFS. (If patient receives surgical oophorectomy, submit this form only once. If patient receives bilateral ovarian radiation therapy, submit until ovarian function suppression is confirmed.) Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
Description
Gnrh Analogue
Description
HormoneTherapyGonadotropin-ReleasingHormoneAnalogAdministeredType
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus Property-2
- C2022
- UMLS 2011AA Property-2
- C1518041
Description
HormoneTherapyLuteinizingHormone-releasingHormoneAgonistAdministrationSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus Property
- C25409
- UMLS 2011AA Property
- C1533734
- NCI Thesaurus Property-2
- C1910
- UMLS 2011AA Property-2
- C1518041
Description
Drug administration method
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0449311
- NCI Metathesaurus ObjectClass
- CL111054
- NCI Thesaurus Property
- C25409
Description
DateAgentAdministered
Data type
text
Description
Administeredby(initials)
Data type
text
Description
BatchNumber
Data type
text
Description
ComplianceCode
Data type
text
Description
Other,specify(compliancecode)
Data type
text
Description
Reasonnottakencode
Data type
text
Description
Adverseevent,specify
Data type
text
Description
Other,specify(reasonnottaken)
Data type
text
Description
Isthisthefinaltreatment?
Data type
boolean
Description
Surgical Oophorectomy
Description
Dateofsurgicaloophorectomy
Data type
text
Description
BilateralOophorectomyPerformedIBCSGInd-2
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus ObjectClass
- C13332
- UMLS 2011AA ObjectClass
- C0238767
- NCI Thesaurus Property
- C38000
- UMLS 2011AA Property
- C0884358
- NCI Thesaurus ObjectClass-2
- C15291
- UMLS 2011AA ObjectClass-2
- C0029936
Description
BilateralOophorectomyPerformedIBCSGSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C13332
- UMLS 2011AA ObjectClass
- C0238767
- NCI Thesaurus Property
- C38000
- UMLS 2011AA Property
- C0884358
- NCI Thesaurus ObjectClass-2
- C15291
- UMLS 2011AA ObjectClass-2
- C0029936
Description
Thisoophorectomyis
Data type
text
Description
OvaryRemovedIBCSGReason
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS 2011AA ValueDomain
- C0392360
- NCI Thesaurus ObjectClass
- C12404
- UMLS 2011AA ObjectClass
- C0029939
- NCI Thesaurus Property
- C25650
- UMLS 2011AA Property
- C0849355
Description
Bilateral Ovarian Radiation Therapy
Description
Confirmation Of Biochemical Evidence Of Cessation Of Ovarian Function After Ovarian Radiotherapy Is Completed.
Description
Estradiolpmol/L
Data type
text
Description
Institutionallowerlimitforpremenopausal
Data type
text
Description
Institutionalupperlimitforpostmenopausal
Data type
text
Description
Dateblooddrawnforthisestradiollevel
Data type
text
Description
Thisradiationtherapyis
Data type
text
Description
RTTreatmentIBCSGReason
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS 2011AA ValueDomain
- C0392360
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C15368
Description
RTTreatmentIBCSGSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C15368
Description
Investigator Signature
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- NCI Thesaurus ObjectClass
- C17089
Description
Investigator Signature Date
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- UMLS CUI-2
- C0011008
- NCI Thesaurus ValueDomain-2
- C25367
- NCI Thesaurus ObjectClass
- C17089
Similar models
OVARIAN FUNCTION SUPPRESSION FORM (Form 24-OFS) Instructions: This form is to be completed and submitted for patients randomized to Ovarian Function Suppression (OFS) and for patients who were not randomized to receive OFS but received it. Submit this form at each follow-up period (every three months in Year 1, every six months in Years 2-6) until the completion of OFS. (If patient receives surgical oophorectomy, submit this form only once. If patient receives bilateral ovarian radiation therapy, submit until ovarian function suppression is confirmed.) Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C0421451 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C25155 (NCI Thesaurus Property)
C0805701 (UMLS 2011AA ValueDomain)
C0034897 (UMLS 2011AA)
C0332307 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C2022 (NCI Thesaurus Property-2)
C1518041 (UMLS 2011AA Property-2)
C0120107 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C0077275 (UMLS 2011AA)
C1521902 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C1910 (NCI Thesaurus Property-2)
C1518041 (UMLS 2011AA Property-2)
C0449311 (UMLS CUI-1)
CL111054 (NCI Metathesaurus ObjectClass)
C25409 (NCI Thesaurus Property)
C0442117 (UMLS 2011AA)
C0443315 (UMLS 2011AA)
C1512698 (UMLS 2011AA ValueDomain)
C13332 (NCI Thesaurus ObjectClass)
C0238767 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15291 (NCI Thesaurus ObjectClass-2)
C0029936 (UMLS 2011AA ObjectClass-2)
C1521902 (UMLS 2011AA ValueDomain)
C13332 (NCI Thesaurus ObjectClass)
C0238767 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15291 (NCI Thesaurus ObjectClass-2)
C0029936 (UMLS 2011AA ObjectClass-2)
C0392360 (UMLS 2011AA ValueDomain)
C12404 (NCI Thesaurus ObjectClass)
C0029939 (UMLS 2011AA ObjectClass)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)
C0205394 (UMLS 2011AA)
C0392360 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA)
C1521902 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)