ID
4703
Description
CALGB: 49903 ADVANCED TREATMENT SUMMARY FORM; All Patients Trastuzumab With or Without Tamoxifen in Treating Women With Progressive Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D1CA4-8ADF-4761-E034-0003BA0B1A09
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Versions (2)
- 8/26/12 8/26/12 -
- 3/20/14 3/20/14 - Martin Dugas
Uploaded on
March 20, 2014
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053339 Treatment - CALGB: 49903 ADVANCED TREATMENT SUMMARY FORM; All Patients - 2054479v3.0
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Description
IDs
Description
Patient Name
Data type
string
Alias
- UMLS CUI
- C1299487
Description
ParticipatingGroup
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Data type
text
Description
ParticipatingGroupProtocolNo.
Data type
text
Description
AffiliateName
Data type
text
Description
ParticipatingGroupPatientID
Data type
text
Description
Treatment Cycle Information
Description
Drug dose
Data type
float
Alias
- UMLS CUI
- C0678766
Description
Agent
Data type
string
Alias
- UMLS CUI
- C0450442
Description
OffTreatmentReason
Data type
string
Alias
- UMLS CUI
- CL436968
Description
OffTreatmentReason,Other
Data type
string
Alias
- UMLS CUI
- CL436968
Description
Treatment Schedule - Systemic Therapy
Description
Treatment Schedule - Other Therapy
Description
OptionalProtocolTherapyInd
Data type
string
Alias
- UMLS CUI
- C1707479
Description
OptionalProtocolTherapyName
Data type
string
Alias
- UMLS CUI
- C1707479
Description
ConcurrentNon-ProtocolTherapyInd
Data type
string
Alias
- UMLS CUI
- C1707479
Description
Concomitant Therapy
Data type
string
Alias
- UMLS CUI
- C1707479
Description
Comments
Description
Signature
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0205394 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)