ID

6355

Description

RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form Higher-Dose Radiation Therapy or Standard Radiation Therapy in Treating Patients With Early-Stage Breast Cancer That Was Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E3CC0E2-B278-1265-E040-BB89AD430CE0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E3CC0E2-B278-1265-E040-BB89AD430CE0

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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NCT01349322 Quality of Life - RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form - 3202750v1.0

English

This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms  
  1. StudyEvent: RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

ProtocolRTOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Case #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C19778
UMLS 2011AA ObjectClass
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C49152
UMLS 2011AA Property
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Description

InstitutionName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution No.
Description

InstitutionIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials
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
RTOG Patient ID
Description

PatientRadiationTherapyOncologyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Are data amended
Description

DataAmendedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unamed Module 2
Description

Unamed Module 2

Will cosmesis photographs be submitted for this time period?
Description

PhotographBreastReconstructionSubmissionInd-3

Data type

text

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
NCI Thesaurus Property
C25351
UMLS 2011AA Property
C0524865
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Time point
Description

AssessmentPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Date photographs taken
Description

PhotographBreastReconstructionTakenDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property
C25351
UMLS 2011AA Property
C0524865
NCI Thesaurus Property
C25701
UMLS 2011AA Property
C1883727
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Date photographs submitted via RTOG website
Description

PhotographBreastReconstructionSubmissionDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
NCI Thesaurus Property
C25351
UMLS 2011AA Property
C0524865
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Reason photographs not submitted
Description

PhotographBreastReconstructionNoSubmissionReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C49487
UMLS 2011AA Property
C1298908
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
NCI Thesaurus Property
C25351
UMLS 2011AA Property
C0524865
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other, specify
Description

PhotographBreastReconstructionNoSubmissionSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C49487
UMLS 2011AA Property
C1298908
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
NCI Thesaurus Property
C25351
UMLS 2011AA Property
C0524865
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C15368
Signature of Person Completing This Form
Description

ResponsiblePersonSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Date Form Completed
Description

FormCompleteDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ValueDomain
C25367
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Similar models

This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms
  1. StudyEvent: RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed Module 1
ProtocolRTOGIdentifierNumber
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass)
C1514695 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property)
C1706256 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
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)
InstitutionIdentifierNumber
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (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)
PatientRadiationTherapyOncologyGroupIdentifierNumber
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Are data amended
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unamed Module 2
Item
Will cosmesis photographs be submitted for this time period?
text
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C25351 (NCI Thesaurus Property)
C0524865 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.2
Code List
Will cosmesis photographs be submitted for this time period?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Time point
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.3
Code List
Time point
CL Item
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
1 Year Post Rt Completion (1 year post RT Completion)
CL Item
3 Years Post Rt Completion (3 years post RT Completion)
PhotographBreastReconstructionTakenDate
Item
Date photographs taken
date
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25351 (NCI Thesaurus Property)
C0524865 (UMLS 2011AA Property)
C25701 (NCI Thesaurus Property)
C1883727 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhotographBreastReconstructionSubmissionDate
Item
Date photographs submitted via RTOG website
date
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C25351 (NCI Thesaurus Property)
C0524865 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Reason photographs not submitted
text
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C49487 (NCI Thesaurus Property)
C1298908 (UMLS 2011AA Property)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C25351 (NCI Thesaurus Property)
C0524865 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.4
Code List
Reason photographs not submitted
CL Item
Other (Other)
CL Item
Patient Death (Patient death)
CL Item
Patient Refused (Patient refused)
CL Item
Patient Too Ill (Patient too ill)
CL Item
Patient Withdrew Consent (Patient withdrew consent)
CL Item
Photographs Not Taken (institution Error) (Photographs not taken (Institution Error))
CL Item
Recurrence / Second Primary (Recurrence / Second Primary)
PhotographBreastReconstructionNoSubmissionSpecify
Item
Other, specify
text
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C49487 (NCI Thesaurus Property)
C1298908 (UMLS 2011AA Property)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C25351 (NCI Thesaurus Property)
C0524865 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ValueDomain)
ResponsiblePersonSignatureText
Item
Signature of Person Completing This Form
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
FormCompleteDate
Item
Date Form Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
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