ID
43191
Description
NSABP B-35 Form ALERT NCT00053898 Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0587E1D-38C6-3AA5-E034-080020C9C0E0
Lien
Mots-clés
Versions (4)
- 26/08/2012 26/08/2012 -
- 08/07/2015 08/07/2015 -
- 08/07/2015 08/07/2015 -
- 20/09/2021 20/09/2021 -
Téléchargé le
20 septembre 2021
DOI
Pour une demande vous connecter.
Licence
Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :
Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.
Groupe Item commentaires pour :
Item commentaires pour :
Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.
NSABP B-35 Form ALERT NCT00053898
Form ALERT Instructions: *Use NCI's Common Toxicity Criteria (CTC) Version 2.0 to assess the adverse event (AE). *Report any grade 3 unexpected AE, or any grade 4 AE, or any grade 5 AE (as listed below). *Complete and FAX this form with all available supporting documentation to the NSABP Biostatistical Center (412/624-1082) within 24 hours of learning about the AE. *Report the AE regardless of attribution (relationship) to protocol therapy (tamoxifen/anastrozole). *Do not fax this report to the NCI, FDA or HPFB.
Description
AE Evaluation
Description
Date of this report (Month Day Year)
Type de données
date
Alias
- UMLS CUI-1
- C1302584
Description
Patient's Age at Time of AE
Type de données
float
Alias
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C20989
- NCI Thesaurus Property-2
- C41331
- NCI Thesaurus ValueDomain
- C29848
- NCI Thesaurus ValueDomain-2
- C25463
- UMLS CUI-1
- C0030705
- UMLS CUI-2
- C0001779
Description
Notify Local IRB?
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C25388
- NCI Thesaurus ObjectClass-2
- C16741
- NCI Thesaurus Property
- C41331
- NCI Thesaurus Property-2
- C25297
- NCI Thesaurus ValueDomain
- C38147
- UMLS CUI-1
- C0086911
- UMLS CUI-2
- C0422202
- UMLS CUI-3
- C1512698
Description
Institution Number
Type de données
float
Alias
- UMLS CUI-1
- C1272753
- UMLS CUI-2
- C0237753
Description
Specify Type of Adverse Event (AE)
Type de données
text
Alias
- UMLS CUI-1
- C0877248
- UMLS CUI-2
- C1521902
Description
AE (CTC Term)
Type de données
text
Alias
- UMLS CUI-1
- C1879645
Description
4-Character NSABP Code
Type de données
text
Alias
- UMLS CUI-1
- C1513905
- UMLS CUI-2
- C0805701
Description
Date of Adverse Event (Month Day Year)
Type de données
date
Alias
- UMLS CUI-1
- C2985916
Description
PatientHospitalizationInd-2
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25179
- UMLS 2011AA Property
- C0019993
Description
Attribution (relationship) of the AE to protocol therapy?
Type de données
text
Alias
- UMLS CUI-1
- C1510821
- UMLS CUI-2
- C0054605
Description
TamoxifenAnastrozole /Start Date (Month Day Year)
Type de données
date
Alias
- UMLS CUI-1
- C0039286
- UMLS CUI-2
- C0290883
- UMLS CUI-3
- C2708155
Description
Tamoxifen/Anastrozole Date of Most Recent Dose (Month Day Year)
Type de données
date
Alias
- UMLS CUI-1
- C0039286
- UMLS CUI-2
- C0290883
- UMLS CUI-3
- C1762893
Description
Briefly describe the AE (provide supporting documentation)
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C0877248
- UMLS CUI-2
- C0678257
Similar models
Form ALERT Instructions: *Use NCI's Common Toxicity Criteria (CTC) Version 2.0 to assess the adverse event (AE). *Report any grade 3 unexpected AE, or any grade 4 AE, or any grade 5 AE (as listed below). *Complete and FAX this form with all available supporting documentation to the NSABP Biostatistical Center (412/624-1082) within 24 hours of learning about the AE. *Report the AE regardless of attribution (relationship) to protocol therapy (tamoxifen/anastrozole). *Do not fax this report to the NCI, FDA or HPFB.
C0030705 (UMLS CUI-2)
C0027365 (UMLS CUI-2)
C1301584 (UMLS CUI-2)
C1515258 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C3262828 (UMLS CUI-1)
C1443235 (UMLS CUI-2)
C3262828 (UMLS CUI-1)
C1515258 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI-1)
C1691222 (UMLS CUI-2)
C20989 (NCI Thesaurus Property)
C41331 (NCI Thesaurus Property-2)
C29848 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0030705 (UMLS CUI-1)
C0001779 (UMLS CUI-2)
C16741 (NCI Thesaurus ObjectClass-2)
C41331 (NCI Thesaurus Property)
C25297 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C0086911 (UMLS CUI-1)
C0422202 (UMLS CUI-2)
C1512698 (UMLS CUI-3)
C0237753 (UMLS CUI-2)
C1521902 (UMLS CUI-2)
C1519789 (UMLS CUI-2)
C1517874 (UMLS CUI-2)
C1517874 (UMLS CUI-2)
C1705232 (UMLS CUI-2)
C1705232 (UMLS CUI-2)
C0805701 (UMLS CUI-2)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25179 (NCI Thesaurus Property)
C0019993 (UMLS 2011AA Property)
C0054605 (UMLS CUI-2)
C0445356 (UMLS CUI-1)
C0290883 (UMLS CUI-2)
C2708155 (UMLS CUI-3)
C0290883 (UMLS CUI-2)
C1762893 (UMLS CUI-3)
C0877248 (UMLS CUI-1)
C0678257 (UMLS CUI-2)