ID

6298

Description

S0100 MAINTENANCE TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB50F10-EF45-43A0-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB50F10-EF45-43A0-E034-0003BA12F5E7

Mots-clés

Versions (1)
  1. 18/12/2014 18/12/2014 - Martin Dugas
Téléchargé le

18 décembre 2014

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :

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Leukemia null Treatment - S0100 MAINTENANCE TREATMENT FORM - 2071555v3.0

Anglais

No Instruction available.

1 Formulaires  
  1. StudyEvent: S0100 MAINTENANCE TREATMENT FORM
    1. No Instruction available.
Physical
Description

Physical

Weight (kg)
Description

PatientWeight

Type de données

double

BSA (M2)
Description

BodySurfaceArea

Type de données

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Treatment
Description

Treatment

Other growth factor, specify
Description

AgentName

Type de données

text

Other growth factor, specify
Description

AgentName

Type de données

text

Start Date
Description

TreatmentStartDate

Type de données

date

Stop Date
Description

TreatmentEndDate

Type de données

date

Total dose given
Description

AgentTotalDose

Type de données

double

Dose Modifications
Description

Dose Modifications

Were there any dose modifications or additions/omissions to protocol treatment? (check one)
Description

DoseModification(Change)

Type de données

text

Yes, Unplanned, specify change (** Explain modifications to dose and/or course and reasons for modification)
Description

DoseModificationReason

Type de données

text

Comments
Description

Comments

Ccrr Module For S0100 Maintenance Treatment Form
Description

Ccrr Module For S0100 Maintenance Treatment Form

SWOG Patient ID
Description

SWOGPatientID

Type de données

text

SWOG Study No.
Description

SWOGStudyNo.

Type de données

text

Registration Step
Description

RegistrationStep

Type de données

text

Patient Initials (L, F, M)
Description

PatientInitials

Type de données

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Type de données

text

Physician
Description

TreatingPhysician

Type de données

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Cycle (check only one)
Description

CourseIdentification

Type de données

text

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Similar models

No Instruction available.

1 Formulaires
  1. StudyEvent: S0100 MAINTENANCE TREATMENT FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Physical
PatientWeight
Item
Weight (kg)
double
BodySurfaceArea
Item
BSA (M2)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
Item Group
Treatment
AgentName
Item
Other growth factor, specify
text
AgentName
Item
Other growth factor, specify
text
TreatmentStartDate
Item
Start Date
date
TreatmentEndDate
Item
Stop Date
date
AgentTotalDose
Item
Total dose given
double
Item Group
Dose Modifications
Item
Were there any dose modifications or additions/omissions to protocol treatment? (check one)
text
CL.2
Code List
Were there any dose modifications or additions/omissions to protocol treatment? (check one)
CL Item
(i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned (i.e., the treatment was changed according to protocol guidelines))
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned (i.e., the treatment change was not part of protocol guidelines))
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
DoseModificationReason
Item
Yes, Unplanned, specify change (** Explain modifications to dose and/or course and reasons for modification)
text
Item Group
Comments
Item Group
Ccrr Module For S0100 Maintenance Treatment Form
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F, M)
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
Item
Cycle (check only one)
text
CL.3
Code List
Cycle (check only one)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
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