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ID

43104

Description

E4599 On-Study Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A1346A5B-91C6-6A0E-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A1346A5B-91C6-6A0E-E034-080020C9C0E0

Keywords

  1. 12/16/14 12/16/14 - Martin Dugas
  2. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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    Lung Cancer null On-Study - E4599 On-Study Form - 2036140v3.0

    No Instruction available.

    1. StudyEvent: E4599 On-Study Form
      1. No Instruction available.
    On-study form
    Description

    On-study form

    Date of data transfer
    Description

    Dateofdatatransfer

    Data type

    text

    Transfer Method
    Description

    TransferMethod

    Data type

    text

    Specify other transfer method
    Description

    Specifyothertransfermethod

    Data type

    text

    Patient Name
    Description

    PatientName

    Data type

    text

    Particip. Group Protocol Number
    Description

    Particip.GroupProtocolNumber

    Data type

    double

    Patient Study ID, Participating Group
    Description

    PatientStudyID,ParticipatingGroup

    Data type

    text

    Institution Name
    Description

    InstitutionName

    Data type

    text

    Affiliate Name
    Description

    AffiliateName

    Data type

    text

    Patient Height
    Description

    Patient Height

    Data type

    integer

    Measurement units
    • cm
    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25347 (undefined)
    UMLS CUI-1
    C0489786 (Height)
    LOINC
    LP72681-7
    cm
    Body Surface Area
    Description

    Body Surface Area

    Data type

    float

    Measurement units
    • m2
    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25157 (undefined)
    UMLS CUI-1
    C0005902 (Body Surface Area)
    SNOMED
    301898006
    m2
    Patient Weight
    Description

    Patient Weight

    Data type

    float

    Measurement units
    • kg
    Alias
    UMLS CUI-1
    C1305866 (Weighing patient)
    SNOMED
    39857003
    kg
    Performance Status
    Description

    PerformanceStatus

    Data type

    text

    Urine dipstick result
    Description

    Urinedipstickresult

    Data type

    text

    Date of urine dipstick
    Description

    Dateofurinedipstick

    Data type

    text

    Date of 24 hour urine for protein
    Description

    Dateof24hoururineforprotein

    Data type

    text

    Weight Loss Prior Six Months
    Description

    Weight Loss past 6 months

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C3445 (undefined)
    UMLS CUI-1
    C1262477 (Weight decreased)
    SNOMED
    161832001
    UMLS CUI-2
    C3828652 (Past 6 Months)
    Protein in urine (mg/24hr)
    Description

    Proteininurine(mg/24hr)

    Data type

    text

    Stage Grouping
    Description

    StageGrouping

    Data type

    text

    Histologic Type
    Description

    HistologicType

    Data type

    text

    Histologic Type, Other Name
    Description

    HistologicType,OtherName

    Data type

    text

    Disease Assessment, Measurable Ind
    Description

    DiseaseAssessment,MeasurableInd

    Data type

    text

    Disease Assessment, Non-measurable Ind
    Description

    DiseaseAssessment,Non-measurableInd

    Data type

    text

    Metastatic Site
    Description

    MetastaticSite

    Data type

    text

    Metastatic Site Indicator
    Description

    MetastaticSiteIndicator

    Data type

    text

    Pleural Effusion Ind
    Description

    PleuralEffusionInd

    Data type

    text

    Pleural Effusion, Malignant Ind
    Description

    PleuralEffusion,MalignantInd

    Data type

    text

    Lab Unit Type
    Description

    LabUnitType

    Data type

    text

    Assessment Type, Target
    Description

    AssessmentType

    Data type

    text

    Lab, Chemistry, Albumin
    Description

    Lab,Chemistry,Albumin

    Data type

    double

    Date Albumin Obtained
    Description

    DateAlbuminObtained

    Data type

    text

    LDH LLN
    Description

    LDHLLN

    Data type

    text

    Lab, Chemistry, Lactate Dehydrogenase
    Description

    Lab,Chemistry,LactateDehydrogenase

    Data type

    double

    Date LDH Obtained
    Description

    DateLDHObtained

    Data type

    text

    Prior Surgery Ind
    Description

    PriorSurgeryInd

    Data type

    text

    Prior Chemotherapy Ind
    Description

    PriorChemotherapyInd

    Data type

    text

    Prior RT Ind
    Description

    PriorRTInd

    Data type

    text

    Prior other systemic therapy
    Description

    Prior Other Systemic Therapy

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C17649 (undefined)
    NCI Thesaurus ObjectClass
    C15698 (undefined)
    NCI Thesaurus ObjectClass
    C25629 (undefined)
    NCI Thesaurus Property
    C25382 (undefined)
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    Prior RT End Date
    Description

    PriorRTEndDate

    Data type

    date

    Other systemic therapy, specify
    Description

    Othersystemictherapy,specify

    Data type

    text

    Date of last dose
    Description

    Last Dose Date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    NCI Thesaurus ObjectClass
    C25488 (undefined)
    NCI Thesaurus ObjectClass
    C25551 (undefined)
    NCI Thesaurus Property
    C25275 (undefined)
    Comments
    Description

    Comments

    Data type

    text

    Comments2
    Description

    Comments2

    Data type

    text

    Patient Race/Ethnicity
    Description

    Patient Race

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C17049 (undefined)
    UMLS CUI-1
    C0034510 (Racial group)
    SNOMED
    415229000
    LOINC
    LP7528-5
    Payment Method
    Description

    PaymentMethod

    Data type

    text

    Amended Data Ind
    Description

    AmendedDataInd

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    UMLS 2011AA ObjectClass
    C1511726 (Data)
    NCI Thesaurus Property
    C25416 (undefined)
    UMLS 2011AA Property
    C1691222 (Amended)
    Step Number
    Description

    StepNumber

    Data type

    text

    Similar models

    No Instruction available.

    1. StudyEvent: E4599 On-Study Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    On-study form
    Dateofdatatransfer
    Item
    Date of data transfer
    text
    TransferMethod
    Item
    Transfer Method
    text
    Specifyothertransfermethod
    Item
    Specify other transfer method
    text
    PatientName
    Item
    Patient Name
    text
    Particip.GroupProtocolNumber
    Item
    Particip. Group Protocol Number
    double
    PatientStudyID,ParticipatingGroup
    Item
    Patient Study ID, Participating Group
    text
    InstitutionName
    Item
    Institution Name
    text
    AffiliateName
    Item
    Affiliate Name
    text
    Patient Height
    Item
    Patient Height
    integer
    C16960 (NCI Thesaurus ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0489786 (UMLS CUI-1)
    Body Surface Area
    Item
    Body Surface Area
    float
    C16960 (NCI Thesaurus ObjectClass)
    C25157 (NCI Thesaurus Property)
    C0005902 (UMLS CUI-1)
    Patient Weight
    Item
    Patient Weight
    float
    C1305866 (UMLS CUI-1)
    PerformanceStatus
    Item
    Performance Status
    text
    Urinedipstickresult
    Item
    Urine dipstick result
    text
    Dateofurinedipstick
    Item
    Date of urine dipstick
    text
    Dateof24hoururineforprotein
    Item
    Date of 24 hour urine for protein
    text
    Weight Loss past 6 months
    Item
    Weight Loss Prior Six Months
    float
    C16960 (NCI Thesaurus ObjectClass)
    C3445 (NCI Thesaurus Property)
    C1262477 (UMLS CUI-1)
    C3828652 (UMLS CUI-2)
    Proteininurine(mg/24hr)
    Item
    Protein in urine (mg/24hr)
    text
    StageGrouping
    Item
    Stage Grouping
    text
    HistologicType
    Item
    Histologic Type
    text
    HistologicType,OtherName
    Item
    Histologic Type, Other Name
    text
    DiseaseAssessment,MeasurableInd
    Item
    Disease Assessment, Measurable Ind
    text
    DiseaseAssessment,Non-measurableInd
    Item
    Disease Assessment, Non-measurable Ind
    text
    MetastaticSite
    Item
    Metastatic Site
    text
    MetastaticSiteIndicator
    Item
    Metastatic Site Indicator
    text
    PleuralEffusionInd
    Item
    Pleural Effusion Ind
    text
    PleuralEffusion,MalignantInd
    Item
    Pleural Effusion, Malignant Ind
    text
    LabUnitType
    Item
    Lab Unit Type
    text
    AssessmentType
    Item
    Assessment Type, Target
    text
    Lab,Chemistry,Albumin
    Item
    Lab, Chemistry, Albumin
    double
    DateAlbuminObtained
    Item
    Date Albumin Obtained
    text
    LDHLLN
    Item
    LDH LLN
    text
    Lab,Chemistry,LactateDehydrogenase
    Item
    Lab, Chemistry, Lactate Dehydrogenase
    double
    DateLDHObtained
    Item
    Date LDH Obtained
    text
    PriorSurgeryInd
    Item
    Prior Surgery Ind
    text
    PriorChemotherapyInd
    Item
    Prior Chemotherapy Ind
    text
    PriorRTInd
    Item
    Prior RT Ind
    text
    Prior Other Systemic Therapy
    Item
    Prior other systemic therapy
    boolean
    C17649 (NCI Thesaurus ObjectClass)
    C15698 (NCI Thesaurus ObjectClass)
    C25629 (NCI Thesaurus ObjectClass)
    C25382 (NCI Thesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    PriorRTEndDate
    Item
    Prior RT End Date
    date
    Othersystemictherapy,specify
    Item
    Other systemic therapy, specify
    text
    Last Dose Date
    Item
    Date of last dose
    date
    C25164 (NCI Thesaurus ValueDomain)
    C25488 (NCI Thesaurus ObjectClass)
    C25551 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    Comments
    Item
    Comments
    text
    Comments2
    Item
    Comments2
    text
    Patient Race
    Item
    Patient Race/Ethnicity
    text
    C16960 (NCI Thesaurus ObjectClass)
    C17049 (NCI Thesaurus Property)
    C0034510 (UMLS CUI-1)
    PaymentMethod
    Item
    Payment Method
    text
    AmendedDataInd
    Item
    Amended Data Ind
    text
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    StepNumber
    Item
    Step Number
    text

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