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6361

Description

Unknown Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=109F4E7D-3810-226A-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=109F4E7D-3810-226A-E044-0003BA3F9857

Keywords

Versions (4)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/16/15 6/16/15 -
  4. 9/20/21 9/20/21 -
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December 18, 2014

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    On-Study - Unknown ECOG Lung Onstudy - 2468160v1.0

    English

    INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files

    1 forms  
    Unnamed1
    Description

    Unnamed1

    ECOG Protocol Number
    Description

    ProtocolECOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    ECOG Patient ID
    Description

    PatientECOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    DCI Name
    Description

    CollectedDataFormName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C19464
    UMLS 2011AA Property
    C0376315
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus ObjectClass
    C25452
    Registration Step
    Description

    RegistrationStepNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C16154
    UMLS 2011AA Property
    C1704379
    NCI Thesaurus ValueDomain
    C16154
    UMLS 2011AA ValueDomain
    C1704379
    Reporting Period
    Description

    ReportingEvaluationPeriodType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C25214
    UMLS 2011AA ObjectClass
    C0220825
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ObjectClass
    C25651
    UMLS 2011AA ObjectClass
    C0700287
    Unnamed2
    Description

    Unnamed2

    Patient Initials (Last, First)
    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
    ECOG Protocol Number
    Description

    ProtocolECOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    ECOG Patient ID
    Description

    PatientECOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    Participating Group Protocol Number
    Description

    ProtocolParticipatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Patient ID
    Description

    PatientParticipatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Institution/Affiliate
    Description

    CombinedInstitutionName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS 2011AA ObjectClass
    C0205195
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    Unnamed 3
    Description

    Unnamed 3

    Please mark an 'X' if data have been amended (Please circle amended items in red)
    Description

    DataAmendedText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Date data amended (M D Y)
    Description

    DataAmendedDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    NCI Thesaurus ValueDomain
    C25367
    Unnamed3
    Description

    Unnamed3

    ECOG Performance Status
    Description

    PerformanceStatusAssessmentEasternCooperativeOncologyGroupScale

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ValueDomain
    C25491
    UMLS 2011AA ValueDomain
    C1512162
    NCI Thesaurus ObjectClass
    C20641
    UMLS 2011AA ObjectClass
    C1518965
    Height (cm)
    Description

    PatientHeightMeasurement

    Data type

    double

    Measurement units
    • cm
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25347
    UMLS 2011AA Property
    C0489786
    cm
    Weight (kg)
    Description

    PatientWeightMeasurement

    Data type

    double

    Measurement units
    • Kg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25208
    UMLS 2011AA Property
    C0043100
    Kg
    Weight Loss in Previous Six Months
    Description

    PatientWeightLossPercentageScale

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C3445
    UMLS 2011AA Property
    C0043096
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    Description Of Disease At Initial Diagnosis
    Description

    Description Of Disease At Initial Diagnosis

    Date of initial pathologic diagnosis (M D Y)
    Description

    CancerInitialDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    Histologic Type
    Description

    LungTumorHistologicClassificationLungTumorHistologicCategory

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus Property
    C25526
    UMLS 2011AA Property
    C0205462
    NCI Thesaurus Property
    C25161
    UMLS 2011AA Property
    C0008902
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ValueDomain
    C25526
    UMLS 2011AA ValueDomain
    C0205462
    Specify combined/mixed histologic types
    Description

    LungNeoplasmCombinedMixedHistologyClassificationSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus Property
    C25454
    UMLS 2011AA Property
    C0205195
    NCI Thesaurus Property
    C25259
    UMLS 2011AA Property
    C0205430
    NCI Thesaurus Property
    C25526
    UMLS 2011AA Property
    C0205462
    NCI Thesaurus Property
    C25161
    UMLS 2011AA Property
    C0008902
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Specify Other Histologic Type
    Description

    TumorHistologicCategorySpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C25526
    UMLS 2011AA Property
    C0205462
    NCI Thesaurus Property
    C25161
    UMLS 2011AA Property
    C0008902
    Tumor Location Area
    Description

    TumorLungAreaType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C12468
    UMLS 2011AA Property
    C0024109
    NCI Thesaurus Property
    C25244
    UMLS 2011AA Property
    C0205146
    Other specify
    Description

    DiseaseInvolvedSiteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property
    C25547
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    Data Unknown Text
    Description

    DataUnknownText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C17998
    UMLS 2011AA Property
    C0439673
    Stage (as determined by surgical evaluation)
    Description

    LungTumorGroupingStage

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    NCI Thesaurus Property
    C25523
    UMLS 2011AA Property
    C1522242
    Chemotherapy Regimen
    Description

    ChemotherapyRegimenType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C15697
    UMLS 2011AA Property
    C0040808
    History Of Disease
    Description

    History Of Disease

    Resection Type
    Description

    LungResectionType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus Property
    C15232
    UMLS 2011AA Property
    C0728940
    Other, specify
    Description

    LungResectionSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus Property
    C15232
    UMLS 2011AA Property
    C0728940
    Date of Resection
    Description

    PatientSurgicalResectionDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25698
    NCI Thesaurus Property
    C15232
    UMLS 2011AA Property
    C0728940
    Type of Mediastinal Lymph Node Dissection
    Description

    MediastinalLymphNodePhysicalExaminationType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus ObjectClass
    C25310
    UMLS 2011AA ObjectClass
    C1522718
    Other, specify
    Description

    MediastinalLymphNodePhysicalExaminationSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus ObjectClass
    C25310
    UMLS 2011AA ObjectClass
    C1522718
    Date of Lymph Node Dissection
    Description

    MediastinalLymphNodePhysicalExaminationDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus ObjectClass
    C25310
    UMLS 2011AA ObjectClass
    C1522718
    Pre-operative mediastinoscopy
    Description

    PreoperativeMediastinoscopyPerformedInd-2

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16829
    UMLS 2011AA ObjectClass
    C0025065
    NCI Thesaurus ObjectClass
    C54732
    UMLS 2011AA ObjectClass
    C0445204
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Date (If yes)
    Description

    PreoperativeMediastinoscopyPerformedDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16829
    UMLS 2011AA ObjectClass
    C0025065
    NCI Thesaurus ObjectClass
    C54732
    UMLS 2011AA ObjectClass
    C0445204
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Involvement
    Description

    LymphNodeInvolvementType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus Property
    C25547
    Node Levels
    Description

    LungLymphNodeInvolvementStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus Property
    C25548
    UMLS 2011AA Property
    C1314939
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Does the patient have a history of wound healing complications (Patients must have recovered from any wound healing complications prior to study entry)
    Description

    PatientWoundComplicationPersonalMedicalHistoryInd-2

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C3671
    UMLS 2011AA Property
    C0043250
    NCI Thesaurus Property
    C2959
    UMLS 2011AA Property
    C0009566
    NCI Thesaurus Property
    C18772
    UMLS 2011AA Property
    C0262926
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify (If yes:)
    Description

    PatientWoundComplicationPersonalMedicalHistorySpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C3671
    UMLS 2011AA Property
    C0043250
    NCI Thesaurus Property
    C2959
    UMLS 2011AA Property
    C0009566
    NCI Thesaurus Property
    C18772
    UMLS 2011AA Property
    C0262926
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Recovery or Latest Date (last known date of disease activity - M D Y)
    Description

    AdverseEventMostRecentRecoveryDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C41331
    UMLS 2011AA ObjectClass
    C0877248
    NCI Thesaurus Property
    C25746
    UMLS 2011AA Property
    C2004454
    NCI Thesaurus Property
    C25577
    UMLS 2011AA Property
    C1513491
    Baseline Abnormalities
    Description

    Baseline Abnormalities

    CTC Adverse Event Term Type (include subterm if applicable Use CTCAE v3 terminology)
    Description

    CommonToxicityCriteriaAdverseEventTermType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C49704
    UMLS 2011AA ObjectClass
    C1516728
    NCI Thesaurus Property
    C45559
    UMLS 2011AA Property
    C1705313
    CTC Adverse Event Grade (Use grade 1-4 per CTCAE v3)
    Description

    CommonToxicityCriteriaAdverseEventGrade

    Data type

    double

    Alias
    NCI Thesaurus ObjectClass
    C49704
    UMLS 2011AA ObjectClass
    C1516728
    NCI Thesaurus ValueDomain
    C18000
    UMLS 2011AA ValueDomain
    C0919553
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Comments
    Description

    Comments

    Investigator Signature
    Description

    InvestigatorSignatureText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    Investigator Signature Date
    Description

    InvestigatorSignatureDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
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    Similar models

    INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Unnamed1
    ProtocolECOGIdentifierNumber
    Item
    ECOG Protocol Number
    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)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    PatientECOGIdentifierNumber
    Item
    ECOG 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)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    CollectedDataFormName
    Item
    DCI Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C19464 (NCI Thesaurus Property)
    C0376315 (UMLS 2011AA Property)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25452 (NCI Thesaurus ObjectClass)
    RegistrationStepNumber
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C16154 (NCI Thesaurus Property)
    C1704379 (UMLS 2011AA Property)
    C16154 (NCI Thesaurus ValueDomain)
    C1704379 (UMLS 2011AA ValueDomain)
    Item
    Reporting Period
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus ObjectClass)
    C0220825 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25651 (NCI Thesaurus ObjectClass)
    C0700287 (UMLS 2011AA ObjectClass)
    CL.1
    Code List
    Reporting Period
    CL Item
    Baseline (Baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    Item Group
    Unnamed2
    PatientInitialsName
    Item
    Patient Initials (Last, First)
    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)
    ProtocolECOGIdentifierNumber
    Item
    ECOG Protocol Number
    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)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    PatientECOGIdentifierNumber
    Item
    ECOG 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)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    ProtocolParticipatingIdentifierNumber
    Item
    Participating Group Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientParticipatingIdentifierNumber
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CombinedInstitutionName
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C0205195 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    Item Group
    Unnamed 3
    DataAmendedText
    Item
    Please mark an 'X' if data have been amended (Please circle amended items in red)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    DataAmendedDate
    Item
    Date data amended (M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain)
    Item
    ECOG Performance Status
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus ValueDomain)
    C1512162 (UMLS 2011AA ValueDomain)
    C20641 (NCI Thesaurus ObjectClass)
    C1518965 (UMLS 2011AA ObjectClass)
    CL.2
    Code List
    ECOG Performance Status
    CL Item
    Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
    CL Item
    Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
    CL Item
    Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
    CL Item
    Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
    CL Item
    Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
    PatientHeightMeasurement
    Item
    Height (cm)
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0489786 (UMLS 2011AA Property)
    PatientWeightMeasurement
    Item
    Weight (kg)
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25208 (NCI Thesaurus Property)
    C0043100 (UMLS 2011AA Property)
    Item
    Weight Loss in Previous Six Months
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C3445 (NCI Thesaurus Property)
    C0043096 (UMLS 2011AA Property)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    CL.3
    Code List
    Weight Loss in Previous Six Months
    CL Item
    <5% Of Body Weight (<5% of body weight)
    CL Item
    5 To <10% Of Body Weight (5 to < 10% of body weight)
    CL Item
    10 To <20% Of Body Weight (10 -<20% of body weight)
    CL Item
    > Or = 20% Of Body Weight (> or = 20% of body weight)
    Item Group
    Description Of Disease At Initial Diagnosis
    CancerInitialDiagnosisDate
    Item
    Date of initial pathologic diagnosis (M D Y)
    date
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    Item
    Histologic Type
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C25526 (NCI Thesaurus Property)
    C0205462 (UMLS 2011AA Property)
    C25161 (NCI Thesaurus Property)
    C0008902 (UMLS 2011AA Property)
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C25526 (NCI Thesaurus ValueDomain)
    C0205462 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Histologic Type
    CL Item
    Squamous Cell Carcinoma (Squamous cell carcinoma)
    C2929 (NCI Thesaurus)
    C0007137 (UMLS 2011AA)
    CL Item
    Adenocarcinoma (Adenocarcinoma)
    C2852 (NCI Thesaurus)
    C0001418 (UMLS 2011AA)
    CL Item
    Large Cell Carcinoma (Large cell carcinoma)
    C3780 (NCI Thesaurus)
    C0206704 (UMLS 2011AA)
    CL Item
    Bronchoalveolar (bac) (Bronchoalveolar carcinoma (BAC))
    CL Item
    Non-small Cell Lung Cancer (nsclc), Nos (Non-small cell lung cancer NOS)
    CL Item
    Combined/mixed, Specify Subcategories (Combined/mixed)
    CL Item
    Other (Other specify)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    LungNeoplasmCombinedMixedHistologyClassificationSpecify
    Item
    Specify combined/mixed histologic types
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C25454 (NCI Thesaurus Property)
    C0205195 (UMLS 2011AA Property)
    C25259 (NCI Thesaurus Property)
    C0205430 (UMLS 2011AA Property)
    C25526 (NCI Thesaurus Property)
    C0205462 (UMLS 2011AA Property)
    C25161 (NCI Thesaurus Property)
    C0008902 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    TumorHistologicCategorySpecify
    Item
    Specify Other Histologic Type
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C25526 (NCI Thesaurus Property)
    C0205462 (UMLS 2011AA Property)
    C25161 (NCI Thesaurus Property)
    C0008902 (UMLS 2011AA Property)
    Item
    Tumor Location Area
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12468 (NCI Thesaurus Property)
    C0024109 (UMLS 2011AA Property)
    C25244 (NCI Thesaurus Property)
    C0205146 (UMLS 2011AA Property)
    CL.5
    Code List
    Tumor Location Area
    CL Item
    Upper Lobe (right) (Upper Lobe (right))
    CL Item
    Middle Lobe (right) (Middle Lobe (right))
    CL Item
    Lower Lobe (right) (Lower Lobe (right))
    CL Item
    Upper Lobe (left) (Upper Lobe (left))
    CL Item
    Lingula (Lingula)
    CL Item
    Lower Lobe (left) (Lower Lobe (left))
    CL Item
    Other, Specify (Other)
    DiseaseInvolvedSiteSpecify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25547 (NCI Thesaurus Property)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    DataUnknownText
    Item
    Data Unknown Text
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C17998 (NCI Thesaurus Property)
    C0439673 (UMLS 2011AA Property)
    Item
    Stage (as determined by surgical evaluation)
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    C25523 (NCI Thesaurus Property)
    C1522242 (UMLS 2011AA Property)
    CL.6
    Code List
    Stage (as determined by surgical evaluation)
    CL Item
    Ib- T2n0 (IB- T2N0)
    CL Item
    Iia- T1n1 (IIA- T1N1)
    CL Item
    Iib- T2n1 (IIB- T2N1)
    CL Item
    Iib- T3n0 (IIB- T3N0)
    CL Item
    Iiia- T1n2 (IIIA- T1N2)
    CL Item
    Iiia- T2n2 (IIIA- T2N2)
    CL Item
    Iiia- T3n1 (IIIA- T3N1)
    CL Item
    Iiia- T3n2 (IIIA- T3N2)
    Item
    Chemotherapy Regimen
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C15697 (NCI Thesaurus Property)
    C0040808 (UMLS 2011AA Property)
    CL.7
    Code List
    Chemotherapy Regimen
    CL Item
    Carboplatin And Paclitaxel (Carboplatin and Paclitaxel)
    CL Item
    Cisplatin And Vinorelbine (Cisplatin and Vinorelbine)
    CL Item
    Cisplatin And Docetaxel (Cisplatin and Docetaxel)
    CL Item
    Cisplatin And Gemcitabine (Cisplatin and Gemcitabine)
    Item Group
    History Of Disease
    Item
    Resection Type
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C15232 (NCI Thesaurus Property)
    C0728940 (UMLS 2011AA Property)
    CL.8
    Code List
    Resection Type
    CL Item
    Intrapericardial Pneumonectomy (Intrapericardial pneumonectomy)
    CL Item
    Pneumonectomy (Pneumonectomy)
    C15305 (NCI Thesaurus)
    C0032284 (UMLS 2011AA)
    CL Item
    Lobectomy (Lobectomy)
    C15272 (NCI Thesaurus)
    C0023928 (UMLS 2011AA)
    CL Item
    Bilobectomy (Bilobectomy)
    CL Item
    Sleeve Lobectomy (Sleeve lobectomy)
    CL Item
    Lobectomy And Chest Wall Resection (Lobectomy and chest wall resection)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    LungResectionSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C15232 (NCI Thesaurus Property)
    C0728940 (UMLS 2011AA Property)
    PatientSurgicalResectionDate
    Item
    Date of Resection
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25698 (NCI Thesaurus Property)
    C15232 (NCI Thesaurus Property)
    C0728940 (UMLS 2011AA Property)
    Item
    Type of Mediastinal Lymph Node Dissection
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25310 (NCI Thesaurus ObjectClass)
    C1522718 (UMLS 2011AA ObjectClass)
    CL.9
    Code List
    Type of Mediastinal Lymph Node Dissection
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    CL Item
    Incomplete Sampling (Incomplete sampling)
    CL Item
    Systematic Sampling (Systematic sampling)
    CL Item
    Complete Mediastinal Lymph Node Dissection (Complete mediastinal lymph node dissection)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    MediastinalLymphNodePhysicalExaminationSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25310 (NCI Thesaurus ObjectClass)
    C1522718 (UMLS 2011AA ObjectClass)
    MediastinalLymphNodePhysicalExaminationDate
    Item
    Date of Lymph Node Dissection
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25310 (NCI Thesaurus ObjectClass)
    C1522718 (UMLS 2011AA ObjectClass)
    Item
    Pre-operative mediastinoscopy
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16829 (NCI Thesaurus ObjectClass)
    C0025065 (UMLS 2011AA ObjectClass)
    C54732 (NCI Thesaurus ObjectClass)
    C0445204 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    CL.10
    Code List
    Pre-operative mediastinoscopy
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    PreoperativeMediastinoscopyPerformedDate
    Item
    Date (If yes)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16829 (NCI Thesaurus ObjectClass)
    C0025065 (UMLS 2011AA ObjectClass)
    C54732 (NCI Thesaurus ObjectClass)
    C0445204 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Item
    Involvement
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25547 (NCI Thesaurus Property)
    CL.11
    Code List
    Involvement
    CL Item
    Negative (negative)
    C25247 (NCI Thesaurus)
    C0205160 (UMLS 2011AA)
    CL Item
    Positive (positive)
    C25246 (NCI Thesaurus)
    C1446409 (UMLS 2011AA)
    CL Item
    Unknown (unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Node Levels
    text
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25548 (NCI Thesaurus Property)
    C1314939 (UMLS 2011AA Property)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.12
    Code List
    Node Levels
    CL Item
    2r (2R)
    CL Item
    4r (4R)
    CL Item
    10r (10R)
    CL Item
    11r (11R)
    CL Item
    12-13r (12-13R)
    CL Item
    1 (1)
    CL Item
    3 (3)
    CL Item
    5 (5)
    CL Item
    6 (6)
    CL Item
    7 (7)
    CL Item
    2l (2L)
    CL Item
    10l (10L)
    CL Item
    11l (11L)
    CL Item
    12-13l (12-13L)
    Item
    Does the patient have a history of wound healing complications (Patients must have recovered from any wound healing complications prior to study entry)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C3671 (NCI Thesaurus Property)
    C0043250 (UMLS 2011AA Property)
    C2959 (NCI Thesaurus Property)
    C0009566 (UMLS 2011AA Property)
    C18772 (NCI Thesaurus Property)
    C0262926 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.13
    Code List
    Does the patient have a history of wound healing complications (Patients must have recovered from any wound healing complications prior to study entry)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    PatientWoundComplicationPersonalMedicalHistorySpecify
    Item
    Specify (If yes:)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C3671 (NCI Thesaurus Property)
    C0043250 (UMLS 2011AA Property)
    C2959 (NCI Thesaurus Property)
    C0009566 (UMLS 2011AA Property)
    C18772 (NCI Thesaurus Property)
    C0262926 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    AdverseEventMostRecentRecoveryDate
    Item
    Recovery or Latest Date (last known date of disease activity - M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus ObjectClass)
    C0877248 (UMLS 2011AA ObjectClass)
    C25746 (NCI Thesaurus Property)
    C2004454 (UMLS 2011AA Property)
    C25577 (NCI Thesaurus Property)
    C1513491 (UMLS 2011AA Property)
    Item Group
    Baseline Abnormalities
    CommonToxicityCriteriaAdverseEventTermType
    Item
    CTC Adverse Event Term Type (include subterm if applicable Use CTCAE v3 terminology)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C49704 (NCI Thesaurus ObjectClass)
    C1516728 (UMLS 2011AA ObjectClass)
    C45559 (NCI Thesaurus Property)
    C1705313 (UMLS 2011AA Property)
    Item
    CTC Adverse Event Grade (Use grade 1-4 per CTCAE v3)
    double
    C49704 (NCI Thesaurus ObjectClass)
    C1516728 (UMLS 2011AA ObjectClass)
    C18000 (NCI Thesaurus ValueDomain)
    C0919553 (UMLS 2011AA ValueDomain)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    CL.14
    Code List
    CTC Adverse Event Grade (Use grade 1-4 per CTCAE v3)
    CL Item
    Mild Adverse Event (1)
    C41338 (NCI Thesaurus)
    C1513302 (UMLS 2011AA)
    CL Item
    Moderate Adverse Event (2)
    C41339 (NCI Thesaurus)
    C1513374 (UMLS 2011AA)
    CL Item
    Severe Adverse Event (3)
    C41340 (NCI Thesaurus)
    C1519275 (UMLS 2011AA)
    CL Item
    Life-threatening Or Disabling Adverse Event (4)
    Item Group
    Comments
    InvestigatorSignatureText
    Item
    Investigator Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
    InvestigatorSignatureDate
    Item
    Investigator Signature Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
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