ID

6233

Description

SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT SUMMARY FORM (S0227) S0227 Comparison of Cisplatin Combined With Either Paclitaxel or Gemcitabine in Treating Patients With Recurrent, Persistent, or Metastatic Cervical Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C46950-C286-3B4D-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C46950-C286-3B4D-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

December 18, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Cervical Cancer NCT00057928 Treatment - SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT SUMMARY FORM (S0227) - 2057355v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT SUMMARY FORM (S0227)
    1. No Instruction available.
Unnamed1
Description

Unnamed1

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Institution / Affiliate
Description

InstitutionName

Data type

text

Physician (Groups other than SWOG)
Description

RegisteredInvestigator

Data type

text

Group Name
Description

ParticipatingGroupName

Data type

text

Study No.
Description

NCIProtocolNumber

Data type

text

Pt. ID
Description

Pt.ID

Data type

text

Status
Description

Status

Date of Last Contact or Death
Description

DeathDate/LastContactDate

Data type

date

Vital Status
Description

Patient'sVitalStatus

Data type

text

Treatment For Cycles 2-6
Description

Treatment For Cycles 2-6

Were there any dose modifications or additions/omissions to protocol treatment
Description

DoseModification(Change)

Data type

text

Cycle 2
Description

Cycle 2

Cycle Start Date
Description

CourseBeginDate

Data type

date

Cycle Stop Date
Description

CycleStopDate

Data type

text

Weight (First day of this cycle)
Description

PatientWeight

Data type

double

BSA (First day of this cycle)
Description

BodySurfaceArea

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Cycle 3
Description

Cycle 3

Cycle Start Date
Description

CourseBeginDate

Data type

date

Cycle Stop Date
Description

CycleStopDate

Data type

text

Weight (First day of this cycle)
Description

PatientWeight

Data type

double

BSA (First day of this cycle)
Description

BodySurfaceArea

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Cycle 4
Description

Cycle 4

Cycle Start Date
Description

CourseBeginDate

Data type

date

Cycle Stop Date
Description

CycleStopDate

Data type

text

Weight (First day of this cycle)
Description

PatientWeight

Data type

double

BSA (First day of this cycle)
Description

BodySurfaceArea

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Cycle 5
Description

Cycle 5

Cycle Start Date
Description

CourseBeginDate

Data type

date

Cycle Stop Date
Description

CycleStopDate

Data type

text

Weight (First day of this cycle)
Description

PatientWeight

Data type

double

BSA (First day of this cycle)
Description

BodySurfaceArea

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Cycle 6
Description

Cycle 6

Cycle Start Date
Description

CourseBeginDate

Data type

date

Cycle Stop Date
Description

CycleStopDate

Data type

text

Weight (First day of this cycle)
Description

PatientWeight

Data type

double

BSA (First day of this cycle)
Description

BodySurfaceArea

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Total dose for this cycle: gemcitabine (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

double

Others, specify
Description

AgentName

Data type

text

Others, specify
Description

AgentName

Data type

text

Others, specify
Description

AgentName

Data type

text

Others, specify
Description

AgentName

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Ccrr Module For Southwest Oncology Group S0227 Treatment Summary Form (s0227)
Description

Ccrr Module For Southwest Oncology Group S0227 Treatment Summary Form (s0227)

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT SUMMARY FORM (S0227)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitialsName
Item
Patient Initials (L, F M)
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)
InstitutionName
Item
Institution / Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
ParticipatingGroupName
Item
Group Name
text
NCIProtocolNumber
Item
Study No.
text
Pt.ID
Item
Pt. ID
text
Item Group
Status
DeathDate/LastContactDate
Item
Date of Last Contact or Death
date
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
Treatment For Cycles 2-6
Item
Were there any dose modifications or additions/omissions to protocol treatment
text
CL.2
Code List
Were there any dose modifications or additions/omissions to protocol treatment
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
(i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned, specify in comments)
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned, specify in comments)
Item Group
Cycle 2
CourseBeginDate
Item
Cycle Start Date
date
CycleStopDate
Item
Cycle Stop Date
text
PatientWeight
Item
Weight (First day of this cycle)
double
BodySurfaceArea
Item
BSA (First day of this cycle)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
Item Group
Cycle 3
CourseBeginDate
Item
Cycle Start Date
date
CycleStopDate
Item
Cycle Stop Date
text
PatientWeight
Item
Weight (First day of this cycle)
double
BodySurfaceArea
Item
BSA (First day of this cycle)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
Item Group
Comments
Comments
Item
Comments
text
Item Group
Cycle 4
CourseBeginDate
Item
Cycle Start Date
date
CycleStopDate
Item
Cycle Stop Date
text
PatientWeight
Item
Weight (First day of this cycle)
double
BodySurfaceArea
Item
BSA (First day of this cycle)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
Item Group
Cycle 5
CourseBeginDate
Item
Cycle Start Date
date
CycleStopDate
Item
Cycle Stop Date
text
PatientWeight
Item
Weight (First day of this cycle)
double
BodySurfaceArea
Item
BSA (First day of this cycle)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
Item Group
Cycle 6
CourseBeginDate
Item
Cycle Start Date
date
CycleStopDate
Item
Cycle Stop Date
text
PatientWeight
Item
Weight (First day of this cycle)
double
BodySurfaceArea
Item
BSA (First day of this cycle)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentTotalDose(percourse)
Item
Total dose for this cycle: gemcitabine (Arm 2 only)
double
AgentName
Item
Others, specify
text
AgentName
Item
Others, specify
text
AgentName
Item
Others, specify
text
AgentName
Item
Others, specify
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group S0227 Treatment Summary Form (s0227)
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