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ACNS0122 Death Worksheet Neoadjuvant Chemotherapy With or Without Second-Look Surgery Followed by Radiation Therapy With or Without Peripheral Stem Cell Transplantation in Treating Patients With Intracranial Germ Cell Tumors Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD40BB6B-6EA3-0C19-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD40BB6B-6EA3-0C19-E034-0003BA12F5E7

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Versionen (3)
  1. 26.08.12 26.08.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 05.07.15 05.07.15 -
Hochgeladen am

26. August 2012

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    Brain and Central Nervous System Tumors NCT00047320 Follow-Up - ACNS0122 Death Worksheet - 2168440v3.0

    Englisch

    No Instruction available.

    1 Formulare  
    1. StudyEvent: ACNS0122 Death Worksheet
      1. No Instruction available.
    Unnamed1
    Beschreibung

    Unnamed1

    Institution Name
    Beschreibung

    InstitutionName

    Datentyp

    text

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    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ObjectClass
    C21541 (undefined)
    UMLS 2011AA ObjectClass
    C0018704 (Health care facility)
    SNOMED
    257622000
    LOINC
    LA30302-6
    NCI Thesaurus ValueDomain
    C21541 (undefined)
    UMLS 2011AA ValueDomain
    C0018704 (Health care facility)
    SNOMED
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    LOINC
    LA30302-6
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    COG Study No
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    Alias
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    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
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    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    COG Study No
    Beschreibung

    ProtocolCOGIdentifierNumber

    Datentyp

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    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    COG Patient ID
    Beschreibung

    PatientCOGIdentifierNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property
    C39353 (undefined)
    UMLS 2011AA Property
    C1516477 (Children's Oncology Group)
    Patient Initials
    Beschreibung

    PatientInitialsName

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25536 (undefined)
    UMLS 2011AA Property
    C1555582 (Initial (abbreviation))
    Today's date
    Beschreibung

    FormOriginalCompleteDate

    Datentyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464 (undefined)
    UMLS 2011AA ObjectClass
    C0376315 (Manufactured form)
    LOINC
    LP29994-8
    NCI Thesaurus Property
    C25250 (undefined)
    UMLS 2011AA Property
    C0205197 (Complete)
    SNOMED
    255594003
    LOINC
    LA13937-0
    NCI Thesaurus Property
    C25604 (undefined)
    UMLS 2011AA Property
    C0205313 (Original)
    SNOMED
    19535007
    LOINC
    LA9505-4
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain
    C25367 (undefined)
    Date worksheet entered into RDE
    Beschreibung

    DataEnteredDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    UMLS 2011AA ObjectClass
    C1511726 (Data)
    NCI Thesaurus Property
    C37949 (undefined)
    UMLS 2011AA Property
    C1521975 (Entered)
    Unnamed2
    Beschreibung

    Unnamed2

    Date of Death
    Beschreibung

    PatientLastContactDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus ValueDomain
    C25367 (undefined)
    NCI Thesaurus Property
    C25461 (undefined)
    UMLS 2011AA Property
    C0337611 (contact person)
    SNOMED
    70862002
    Contributing Cause of Death
    Beschreibung

    PatientDeathReason

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638 (undefined)
    UMLS 2011AA ValueDomain
    C0392360 (Indication of (contextual qualifier))
    SNOMED
    230165009
    LOINC
    MTHU008319
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C28554 (undefined)
    UMLS 2011AA Property
    C0011065 (Cessation of life)
    SNOMED
    419620001
    NCI Thesaurus ValueDomain
    C28554 (undefined)
    UMLS 2011AA ValueDomain
    C0011065 (Cessation of life)
    SNOMED
    419620001
    Primary cause of Death
    Beschreibung

    PatientDeathPrimaryReason

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638 (undefined)
    UMLS 2011AA ValueDomain
    C0392360 (Indication of (contextual qualifier))
    SNOMED
    230165009
    LOINC
    MTHU008319
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C28554 (undefined)
    UMLS 2011AA Property
    C0011065 (Cessation of life)
    SNOMED
    419620001
    NCI Thesaurus ValueDomain
    C28554 (undefined)
    UMLS 2011AA ValueDomain
    C0011065 (Cessation of life)
    SNOMED
    419620001
    please specify [primary cause of death] (If 'Other',)
    Beschreibung

    PatientDeathSpecify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS 2011AA ValueDomain
    C1521902 (To specify)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C28554 (undefined)
    UMLS 2011AA Property
    C0011065 (Cessation of life)
    SNOMED
    419620001
    please specify [primary cause of death] (If 'Other',)
    Beschreibung

    PatientDeathSpecify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS 2011AA ValueDomain
    C1521902 (To specify)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C28554 (undefined)
    UMLS 2011AA Property
    C0011065 (Cessation of life)
    SNOMED
    419620001
    Autopsy?
    Beschreibung

    AutopsyPerformedInd-3

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS 2011AA ValueDomain
    C1512699 (Yes, No, or Unknown Response)
    NCI Thesaurus ObjectClass
    C25153 (undefined)
    UMLS 2011AA ObjectClass
    C0004398 (Autopsy)
    SNOMED
    29240004
    LOINC
    LA20097-4
    NCI Thesaurus Property
    C38000 (undefined)
    UMLS 2011AA Property
    C0884358 (Performed)
    SNOMED
    398166005
    LOINC
    LA19974-7
    How were the side effects of protocol therapy related to the patient's death?
    Beschreibung

    DeathClinicalTrialProtocolAttributionDeathAttributionType

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C28554 (undefined)
    UMLS 2011AA ObjectClass
    C0011065 (Cessation of life)
    SNOMED
    419620001
    NCI Thesaurus Property
    C25320 (undefined)
    UMLS 2011AA Property
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C25358 (undefined)
    UMLS 2011AA Property
    C0596130 (Attribution)
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    NCI Thesaurus ValueDomain
    C28554 (undefined)
    UMLS 2011AA ValueDomain
    C0011065 (Cessation of life)
    SNOMED
    419620001
    Unnamed3
    Beschreibung

    Unnamed3

    Comments
    Beschreibung

    ResearchCommentsText

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ObjectClass
    C15319 (undefined)
    NCI Thesaurus Property
    C25393 (undefined)
    UMLS 2011AA Property
    C0282411 (Published Comment)
    LOINC
    MTHU018874
    Ccrr Module For Acns0122 Death Worksheet
    Beschreibung

    Ccrr Module For Acns0122 Death Worksheet

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    1 Formulare
    1. StudyEvent: ACNS0122 Death Worksheet
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Unnamed1
    InstitutionName
    Item
    Institution Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolCOGIdentifierNumber
    Item
    COG Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolCOGIdentifierNumber
    Item
    COG Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientCOGIdentifierNumber
    Item
    COG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C39353 (NCI Thesaurus Property)
    C1516477 (UMLS 2011AA Property)
    PatientInitialsName
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    FormOriginalCompleteDate
    Item
    Today's date
    date
    C19464 (NCI Thesaurus ObjectClass)
    C0376315 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25604 (NCI Thesaurus Property)
    C0205313 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    DataEnteredDate
    Item
    Date worksheet entered into RDE
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C37949 (NCI Thesaurus Property)
    C1521975 (UMLS 2011AA Property)
    Item Group
    Unnamed2
    PatientLastContactDate
    Item
    Date of Death
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25367 (NCI Thesaurus ValueDomain)
    C25461 (NCI Thesaurus Property)
    C0337611 (UMLS 2011AA Property)
    Item
    Contributing Cause of Death
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    C28554 (NCI Thesaurus ValueDomain)
    C0011065 (UMLS 2011AA ValueDomain)
    CL.1
    Code List
    Contributing Cause of Death
    CL Item
    Due To This Disease (Tumor)
    CL Item
    Due To Protocol Treatment ("Drug")
    CL Item
    Other Drug (Other Drug)
    CL Item
    Infection (Infection)
    CL Item
    Hemorrhage (Hemorrhage)
    CL Item
    ARDS (ARDS)
    CL Item
    Multi-Organ Failure (Multi-Organ Failure)
    CL Item
    GVHD (GVHD)
    CL Item
    Due To Other Cause, Specify (Other, Specify)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Primary cause of Death
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    C28554 (NCI Thesaurus ValueDomain)
    C0011065 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Primary cause of Death
    CL Item
    Due To This Disease (Tumor)
    CL Item
    Due To Protocol Treatment ("Drug")
    CL Item
    Other Drug (Other Drug)
    CL Item
    Infection (Infection)
    CL Item
    Hemorrhage (Hemorrhage)
    CL Item
    ARDS (ARDS)
    CL Item
    Multi-Organ Failure (Multi-Organ Failure)
    CL Item
    GVHD (GVHD)
    CL Item
    Due To Other Cause, Specify (Other, Specify)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    PatientDeathSpecify
    Item
    please specify [primary cause of death] (If 'Other',)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    PatientDeathSpecify
    Item
    please specify [primary cause of death] (If 'Other',)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    Item
    Autopsy?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25153 (NCI Thesaurus ObjectClass)
    C0004398 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    CL.3
    Code List
    Autopsy?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    How were the side effects of protocol therapy related to the patient's death?
    text
    C28554 (NCI Thesaurus ObjectClass)
    C0011065 (UMLS 2011AA ObjectClass)
    C25320 (NCI Thesaurus Property)
    C1507394 (UMLS 2011AA Property)
    C25358 (NCI Thesaurus Property)
    C0596130 (UMLS 2011AA Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C28554 (NCI Thesaurus ValueDomain)
    C0011065 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    How were the side effects of protocol therapy related to the patient's death?
    CL Item
    Not Related (Not related)
    C25648 (NCI Thesaurus)
    C0439849 (UMLS 2011AA)
    C25594 (NCI Thesaurus)
    C1518422 (UMLS 2011AA)
    CL Item
    Minor Contribution To Death (Minor contributions to death)
    CL Item
    Major Contribution To Death (Major contributions to death)
    CL Item
    Exclusive Cause Of Death (Exclusive cause of death)
    Item Group
    Unnamed3
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
    Item Group
    Ccrr Module For Acns0122 Death Worksheet
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