ID

4707

Description

CALGB: Secondary Malignancy Form 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=A73D10AA-19A6-4733-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D10AA-19A6-4733-E034-0003BA0B1A09

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 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 Follow-Up - CALGB: Secondary Malignancy Form - 2029264v3.0

English

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. Do not leave any entries blank. Enter -1 to indicate that an answer in unknown, unobtainable, not applicable, or not done. Retain a copy for your records and submit ORIGINAL to the CALGB Data Management Center.

1 forms  
CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Amended data?
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI
C1511726
UMLS CUI
C1691222
Patient's Name
Description

Patient'sName

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Main Member Institution/Adjunct
Description

AffiliateName

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientID

Data type

text

Type of secondary malignancy (site, histology)
Description

Typeofsecondarymalignancy

Data type

text

Date of first pathologic diagnosis of secondary malignancy
Description

Dateoffirstpathologicdiagnosisofsecondarymalignancy

Data type

text

Has FDA Form 3500 (MEDWATCH) or NCI/CTEP Secondary AML/MDS Form been sent to Central Office?
Description

NCI/CTEPSecondaryAML/MDSFormInd

Data type

text

If yes, specify date sent (MEDWATCH)
Description

NCI/CTEPSecondaryAML/MDSFormSentDate

Data type

date

If no, specify reason not sent (MEDWATCH)
Description

NCI/CTEPSecondaryAML/MDSForm,NotSentReason

Data type

text

Comments
Description

Comments

Data type

text

Completed by
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date completed
Description

FormCompletionDate,Original

Data type

date

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Similar models

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. Do not leave any entries blank. Enter -1 to indicate that an answer in unknown, unobtainable, not applicable, or not done. Retain a copy for your records and submit ORIGINAL to the CALGB Data Management Center.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI)
C1691222 (UMLS CUI)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
AffiliateName
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientID
Item
Participating Group Patient No.
text
Typeofsecondarymalignancy
Item
Type of secondary malignancy (site, histology)
text
Dateoffirstpathologicdiagnosisofsecondarymalignancy
Item
Date of first pathologic diagnosis of secondary malignancy
text
Item
Has FDA Form 3500 (MEDWATCH) or NCI/CTEP Secondary AML/MDS Form been sent to Central Office?
text
CL.2
Code List
Has FDA Form 3500 (MEDWATCH) or NCI/CTEP Secondary AML/MDS Form been sent to Central Office?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NCI/CTEPSecondaryAML/MDSFormSentDate
Item
If yes, specify date sent (MEDWATCH)
date
NCI/CTEPSecondaryAML/MDSForm,NotSentReason
Item
If no, specify reason not sent (MEDWATCH)
text
Comments
Item
Comments
text
PersonCompletingForm,FirstName
Item
Completed by
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date completed
date
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